Pursuant to Medicare regulations, in order to be eligible for hospice care, an individual must be certified as “terminally ill” in accordance with Federal Regulations. Under Medicare regulations, “terminally ill” means that a person “has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course.”
Hospice care is available to individuals for two initial ninety (90) day periods, followed by an unlimited number of sixty (60) day periods, provided that at the beginning of each period a physician certifies the individual’s terminal condition in writing.
Unfortunately, some hospice providers routinely certify, and recertify, patients for hospice who are not “terminally ill,” at a great cost to taxpayers.
Based on the number of days and level of care provided, hospices are paid a per diem rate by Medicare. Those rates are significant. For example, hospice providers in Los Angeles receive approximately $5,300, per patient, per month (moreover, if a patient is deemed to require “Continuous Home Care” or “crisis care,” i.e., 24-hour care, the Medicare hospice reimbursement rate for Los Angeles is over $1,000 per day). A false certification or recertification is thus very costly to taxpayers, and very profitable for hospice providers. Patients who should not qualify for hospice are especially profitable, because they typically require less care, and the expenditure of fewer resources.
Falsely certifying patients as eligible for hospice care, or as eligible for “continuous care,” can lead to liability under the False Claims Act. Whistleblowers have brought cases against many hospice companies around the country. For example, the federal Department of Justice has intervened in a case brought by CPM against Vitas Hopsice, the largest hospice company in the United States. The case, brought on behalf of a whistleblower who formerly worked for Vitas, alleges that Vitas routinely placed and kept patients on hospice who did not have a terminal illness. As a result, Vitas billed Medicare tens of millions in taxpayer dollars for services that were not appropriate. CPM is now working with DOJ attorneys to recoup the fraudulent proceeds. The case is being handled by Niall P. McCarthy and Justin T. Berger. The name of the case is United States v. Vitas, USDC Western District of Missouri, Case No. 4:13-cv-00449-BCW.