HOSPICE FRAUD & SCAMS YOU MAY
ENCOUNTER: ? (HOW TO AVOID THEM)
There are numerous documented cases of fraud occurring in the
hospice environment as well as in every other health care field:
i.e. hospitals, nursing homes, home health care, HMO's,
insurance, etc. Of course, if you only read the newspapers and
watched TV you'd never know it at all. Hospice organizations
routinely deny or minimize the significance of fraud in hospice,
often stating that these are very rare exceptions and that most
hospices provide excellent care. However, those of us who have
worked directly in the hospice industry know from the inside that
it is too easy for hospice administrators to set up situations
that result in fraud.
Why Hospice Fraud is So Easy to
Perpetrate
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People generally trust their nurses and other health care
workers. This is especially true when the nurse comes to care for
the dying. People simply cannot imagine that the hospice itself
will take advantage of the patient it is supposed to serve.
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Hospices are often viewed as charitable, compassionate
servants of the dying, when some of the hospices are actually
ruthless businesses that are like wolves taking advantage of the
sheep. News media are reluctant to report documented cases of
hospice fraud, because the trend of the media is to promote
hospice and the care of the dying. How can the media outlets,
such as newspapers, TV and radio stations report on violations by
local hospices when they have recently published articles
promoting the very same hospices committing the fraud?
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Hospice, because of its image as a compassionate service,
attracts prominent business leaders in the local communities, and
many of these prominent business leaders serve on the Board of
Directors of the local hospices. The ol' boy network protects
the hospice even if fraudulent practices are occurring. This
network blocks news coverage, blocks action by local governments
(even at the State government level) and effectively hushes up
the serious abuses by hospices which are occurring.
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As unbelievable as it may be, hospice administrators often DO
NOT teach their staff the full and complete regulations governing
hospice care! They often give their staff inaccurate ideas about
the regulations, saying that whatever the hospice is doing is
absolutely legal, when it is actually felony health care
fraud!
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Hospices manipulate their staff into situations where they
cannot provide the care needed by the patient, due to
intentionally created shortages of staff in key areas such as
"Continuous Nursing Care" for patients in crisis in
their own home. By not making the effort to actually hire
adequate staff, the administration makes sure they cannot provide
nursing services as needed in the home, and the patient is forced
into the hospice facility, against his will!
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Hospices get paid on a "per-diem basis" which means
they get a set amount of money per patient signed on, for each
day the patient is enrolled in the program, regardless of how
many services or medications they provide. The system of
payment financially rewards hospices which skimp on services and
enroll more patients.
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Hospice patients and families are in most cases completely
isolated from other patients and families who might give them
information which could protect them from fraud or inform them of
their rights. In most cases, families are living at home
completely immersed in the time-consuming and exhausting work of
caring for their loved one.
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When patients enroll in the hospice programs, the hospice
admissions staff do not always provide full, informed consent.
Since the patients and families are not fully informed of their
rights, they do not know what services they are entitled to
receive.
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Patients and families are in crisis mode, grieving the
imminent loss of the patient; they cannot muster the energy to
fight the hospice's deception or exploitation, even if they
do know that they're being taken advantage of.
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There is so little time, in many cases, for the patient or
family to resolve problems which the hospice may be causing,
before the patient dies. So when a hospice under-serves the
patient and family, it is out of the picture before anything can
be corrected. Complaints from family members can fall on deaf
ears at the hospice, and appeals to higher levels of management
can result in patronizing insincere apologies from administrators
who are paid to simply make the problem go away. What good does
it do for the hospice to apologize after the patient has already
died, or the family and patient have suffered tragically as a
result of a rogue hospice's intentional wrongdoing?
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Staff who cooperate with a hospice's plans for fraud are
rewarded by promotions and given power within the organization.
The hospice can give pay raises to those who go along with the
policies, even though the policies violate the federal and state
Standards of care for the industry.
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Staff who complain about problems in the hospice are routinely
harassed, intimidated and made to feel so uncomfortable that they
resign, leaving behind them staff who are so afraid of speaking
up that they keep quiet in order to save their jobs.
While some hospice staff and administrators may be shocked by
the thought of such abuse occurring, their shock is only to be
matched by their naivete'. Those hospice staff and
administrators who have integrity cannot believe that anyone
would conceivable take advantage of the dying. Sadly enough, many
do.
Common Examples of Fraud & Scams in
Hospice
While many patients, families, and staff will find it
difficult to explain fraud in hospice, fraud does occur. Many
staff are unaware of the fraud occurring in areas other than
their own area of the hospice's various departments. However,
many staff are aware of such abuses yet remain silent. Taking
advantage of the dying is one of the most despicable crimes one
can think of. Yet there are, unfortunately, unscrupulous
executive level hospice administrators who have no qualms about
violating regulations and patients' rights in order to cash
in on the opportunity to personally make extremely large fortunes
while skimping on services to the patients.
All areas of hospice care may be subject to fraud of
some kind; there is no area of hospice care that can be
ruled out as a possible area for fraud. What must be kept
centrally in mind is that the hospice must provide the services
needed to meet the actual care needs of the patient. The
frequency of services and type of services is NOT determined by
the hospice's apparent problems in staffing; the frequency
and type of services is solely to be determined by your needs!
The hospice is required to meet the needs of the patient and
family. Some examples of hospice fraud are:
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Hospices can reduce the frequency of home health aide visits
to the patient, so the patient is visited less often than really
needed.
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Hospices can reduce the frequency of RN case manager visits to
the patient by requiring the RN's to take on overly large
caseloads or reducing the number of days each RN works per week.
RN's may simply telephone to the patient or family to check
on the patient's condition. A telephone call cannot
substitute for an actual on-site physical assessment of the
patient's condition by the RN.
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Hospices can reduce the availability of RN's, home health
aides, counselors, chaplains, bereavement staff, social workers
and dietitians by consciously choosing to NOT hire adequate
staff, or delay the replacement of staff who resign. Without
adequate staff being hired by the hospice, these hospice staff
will have overly large caseloads and will not be able to visit
and serve the patients according to the actual needs of the
patient.
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Hospices sometimes use Licensed Practical Nurses (LPN's)
or Home Health Aides to perform tasks which only Registered
Nurses (RN's) may properly perform. They may use LPN's or
Home Health Aides in roles which require an RN's supervision,
but not actually provide adequate RN supervision.
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Hospices can skimp on the medications given to the patient for
pain! How? Probably every community has physicians who order
inadequate or ineffective medications for pain control. Some
medications for pain can be quite expensive. The hospice is
legally obligated to make sure the patient gets the medications
needed to control the pain and maintain patient comfort. When a
physician does NOT order adequate pain medication, some hospices
may refuse to intervene on behalf of the patient's comfort.
They choose not to question the physician's orders and
thereby leave the patient in pain, but the hospice saves money by
so doing!
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As cruel as it may seem, some hospices refuse to provide
oxygen to patients who are short of breath or who need oxygen for
other reasons. The staff tell the families it is not needed, even
if the family make suggestions or inquire about it. The hospice
saves money by not having to pay for the oxygen.
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During a crisis, hospices can refuse to provide continuous
around the clock nursing in the patient's own home (not a
hospice facility) and tell the family and patient that the
hospice doesn't have enough staff to provide care in the
home. When the hospice tells the patient and family that there
aren't adequate staff to provide care at home and thereby
keep the patient at home, the patient is often manipulated
against his or her will into the hospice facility, where the
hospice will then collect fees for room and board, which it
wouldn't receive if the patient were kept at home.
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Even after manipulating a patient against his will into its
own facility, the hospice can still bill Medicare, Medicaid or
private insurance for the more highly reimbursed level of care,
such as Continuous Nursing Care or Inpatient Level of Care. The
Continuous Nursing Level of Care may be billed if the facility is
licensed as a "home" and not as a nursing home or
hospice inpatient facility.
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Hospices can ask patients or families to privately pay out of
their own pocket for services which already are being reimbursed,
or will be reimbursed, by Medicare, Medicaid or private insurance
companies. Because of the isolation of the hospice patient or
family, the fraudulent billing to the patient or family may go
undetected completely. If the patient is already dead and the
family wants to put the whole matter behind them, who will report
the additional billing to the Office of Inspector General? If the
patient and family do not know what is being billed to Medicare,
Medicaid or private insurance companies (and they do not know
what the hospice is billing) they have no way of realizing that
double-billing is occurring. If confirmation of reimbursement
from Medicare, Medicaid, or insurance companies arrive in the
home several months later, or even later than that, the family
will often not even read the confirmation of billing or will not
understand that double-billing has occurred.
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Hospices can make fraudulent or otherwise illegal arrangements
with nursing homes or hospitals for referrals. Kickbacks to the
hospital or nursing home for referring patients to the hospice
are illegal. Patients and families would have no way of knowing
about such kickbacks.
What to Look For
Whatever your particular situation, if your loved one is NOT
getting the services needed, if the hospice is trying to talk you
into transferring your loved one to their facility against his or
her will, if your loved one is NOT being kept comfortable, if
there is inadequate staff and you are getting exhausted while
caring for your loved one, you must demand that the hospice
provide the services needed to meet the needs of the family and
patient, whether living at home or in any facility. The law
requires the hospice to meet the needs of the patient and the
family!
What to Do
It is crucial that you read all the printed
literature, documents and contracts you have with the
hospice. These pamphlets, brochures, contracts and
papers must (by law) inform you of your rights to the various
services available through the hospice. Most patients and
families do NOT read all this literature, and thereby they lose
their greatest protection from exploitation...KNOWLEDGE OF THE
REQUIRED SERVICES. Knowing what services are required to be
provided will allow you to make informed decisions about the care
your loved one receives. Knowing what services are required will
help you protect your loved one from exploitation.
If you are not getting the services needed to meet the
patient's and the family's needs, you need to speak with
the RN case manager. If you get the runaround or sophisticated
excuses, you must demand to speak with the hospice's Medical
Director and Manager. If you still do not
quickly get proper action to correct the
problem, put a complaint in writing and send it to your
State's Bureau of Health Systems (which is responsible to
inspect the hospice) immediately and also give a copy to the
hospice.
You may use the form provided on this website to make a
complaint:
Click here for Complaint
Form
You can count on the hospice to move quickly to correct the
situation if you actually put a complaint in to the State. If you
believe there is actual fraud occurring, do not hesitate to
contact both the U.S. Office of Inspector General and your
regional U.S. Attorney's office. They will investigate your
case and may find confirmation of long-standing patterns of
hospice fraud. For direct links to the OIG and U.S.
Attorney's Office/Department of Justice, see the section
within this website for "Links to
Put in a Complaint about Hospice Fraud."
What the Inspector General Says About Hospice
Fraud in Nursing Homes
Although hospices and hospice organizations will deny it, the
United States Department of Health and Human Services - Office of
Inspector General (OIG) has investigated and clearly documented
many cases of fraud in hospice. Because of so many cases of
hospice fraud occurring, in 1995, the OIG released its Fraud
Alert Bulletin detailing types of hospice fraud that may occur
when the patient is residing in a nursing home. This report is
available directly from the OIG at: http://www.oig.hhs.gov/fraud/docs/alertsandbulletins/hospice2.pdf or you can see it online at our website.or you can see it in written form published in the Federal Register: November 2, 1995 (vo. 60, Number 212) which is available at any major public library in your area.
Sept, 2009 US DHHS, Office of Inspector General Report
on Hospice Care for Beneficiaries in Nursing Facilities
In September, 2009, the U.S. Dept of Human Services, Office of Inspector General ("OIG") released a report showing the continuing problem of fraud committed by hospice agencies, this time when nursing home residents are enrolled into hospice programs. The report, entitled, "Medicare Hospice Care For Beneficiaries in Nursing Facilities: Compliance With Medicare Coverage Requirements" provided stunning details of how poorly hospice agencies were performing in nursing home settings! Many of the patients who are enrolled into hospice, but reside in a nursing home, do not receive the full range of services that hospices are required to provide. See the OIG report (or see it mirrored at our own website). The OIG also issued a Memorandum Report which it sent to the US Centers for Medicare Services summarizing the findings in the September, 2009 report and suggesting that the report contained information about the services actually provided to residents in nursing homes, so they might consider adjusting the amounts paid to hospice agencies (with the implication that they should be paid for the services they actually provided rather than what they were supposed to provide and did not). We have mirrored this Memorandum at our website as well.
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