"When hospices increase their bottom lines by billing taxpayers for unneeded services, they are diverting money from vulnerable, terminally-ill individuals," said a spokesperson for the U.S. Department of Health and Human Services Office of the Inspector General. "Worse yet, these patients may not be receiving care for medical needs that would otherwise be covered in a non-hospice setting."
According to the Department of Justice, a for-profit hospice chain called Caris Healthcare set aggressive admissions and census targets, which are known to be a risk for fraud. In order to meet those targets, the government alleges, Caris admitted and often recertified patients for hospice care even though their medical records did not support the terminal prognosis required for Medicare's hospice benefit.
Internal audits, along with concerns raised by the company's chief medical officer and by nurses who examined the patients, alerted Caris that some patients were ineligible. Caris took no meaningful action to find out whether ineligible patients had been admitted and improperly billed to Medicare. Instead, Caris continued to submit claims on the ineligible patients' behalf.
Therefore, the Justice Department accused Caris not only of knowingly submitting false claims but also of knowingly retaining overpayments. Caris has agreed to pay $8.5 million to resolve the allegations.
"Compliance programs and activities cannot exist in name only," said a Justice Department spokesperson. When healthcare providers are made aware that improper billing may have occurred, they cannot simply continue the practice but must take reasonable steps to put a stop to it and to return any overpayments, he added. Moreover, when internal audits reveal compliance issues, due diligence requires providers to determine how widespread the problem is.
The allegations were originally brought in a False Claims Act lawsuit by a registered nurse who had been working for Caris. Private citizens who notice fraud, waste or abuse against government programs can bring such lawsuits on the government's behalf. In some cases, like this one, the government may intervene and take over the case. Whether or not the government intervenes, the citizen whistleblower receives a reward for their actions -- a portion of any money recovered by the government. Here, the whistleblower's share will be $1,402,500.
In American healthcare, innumerable private organizations fulfill government contracts through Medicare, Medicaid, TRICARE and other programs. Many healthcare workers are in a position to notice when false or padded bills are submitted. If you have noticed fraud, waste or abuse in any government contract, you could receive a portion of any recovery in a False Claims Act lawsuit. Protect your eligibility for a reward by contacting a lawyer experienced in False Claims Act and whistleblower law.