A private, for-profit hospice provider and its CEO have agreed to settle False Claims Act allegations brought by the federal government. The company and its head have agreed to pay $1,240,000 to resolve claims that they fraudulently billed Medicare and Medicaid.
According to the U.S. Attorney for the Western District of Pennsylvania, Horizons Hospice, LLC, submitted claims to Medicare and Medicaid for patients who didn't qualify for end-of-life hospice care. The federal healthcare programs typically do not pay for hospice care unless patients have terminal illnesses with a life expectancy prognosis of six months or less, but Horizon and its CEO submitted fraudulent claims. In some cases, the U.S. Attorney also contended that the defendants falsified the medical records that supported the claims so they would seem legitimate. These activities violated the False Claims Act.
"Medicaid and Medicare are programs intended to provide care and assistance to the most vulnerable members of our communities, including seniors," commented the U.S. Attorney. "Those who seek to defraud these programs will be vigorously pursued by my office. This settlement is another step forward in that fight."
The settlement could not have been made without the actions of two whistleblowers. Two former employees filed whistleblower lawsuits in 2012 and 2013 after having "left in disgust" over the fraud. In False Claims Act lawsuits, whistleblowers who expose fraud, waste or abuse in federal programs can obtain a substantial reward for their assistance. That reward is a percentage of the overall recovery.
Beyond the settlement, the situation resulted in at least two criminal convictions. The former chief operations manager of Horizons Hospice pled guilty to healthcare fraud in 2016 and was sentenced to 15 months in prison. At her plea hearing, she admitted having employees admit patients who were not terminally ill in an effort to increase Medicare and Medicaid billings.
The former medical director of the Pittsburgh office also pled guilty to a different offense. The man, a doctor, pled guilty to prescribing some 10,800 oxycodone and 3,600 oxymorphone tablets to patients who had no medical need for the opioid painkillers. He was originally sentenced to more than 11 years in prison but had his sentence reduced because he cooperated with the Horizons case.
Horizons Hospice, LLC, has since changed its name to 365 Hospice LLC. According to the U.S. Attorney's Office, the fraud occurred while the company was operating as Horizons Hospice.