Avoid Hospice Fraud and Find Your Best Provider

The hospice benefit was created in the 1980s, but there has been a recent uptick in consumer knowledge, due to national attention on positive experiences for people like former President Jimmy Carter, who spent nearly two years on hospice.

Hospice care offers a vital and compassionate service, but, like any industry, there are instances of unethical practices. Exploiting individuals who are nearing the end of life, along with their families, is a deeply reprehensible act, yet hospice fraud is thriving. 

“The hospice benefit was created in the 1980s and was intended to be service mission driven part of health care, but fraud in the field is a very big concern,” says Cheryl Fried, CEO of Kirva Hospice. “Consumers should always be on the lookout for every health care provider and the potential of fraud in their delivery of care and service.” Although fraud tends to be more prevalent in the more highly populated areas of the country such as Texas, California, and Nevada, and New York, Fried adds, fraud can happen anywhere. 

Types of hospice fraud

Hospice fraud refers to illegal or unethical practices within the hospice care system, often aimed at obtaining financial gain through deception. Hospice fraud include:

Upcoding and billing for unnecessary services

This happens when a hospice provider bills for services that were unnecessary or not provided. It can also include billing for more expensive services or longer care periods than were actually required.

False eligibility

Fraudulent hospice providers may falsify documents to make patients appear eligible for hospice care when they are not. For example, they may certify patients as terminally ill (with a prognosis of six months or less) when this is not the case, enabling the provider to directly receive Medicare reimbursements.

Kickbacks and referral fraud

In this form of fraud, hospice providers offer or accept illegal kickbacks or bribes in exchange for patient referrals from doctors, nursing homes, or other health care providers. These unethical arrangements result in patients receiving hospice care they may not need or want – sometimes without even being aware of it.

Providing care to ineligible patients

Although legitimate hospice care needs might range anywhere from a day to years, some hospice providers may continue offering care to patients who no longer meet the eligibility criteria, such as patients who have recovered or improved beyond the point of being considered terminally ill. Continuing care for ineligible patients leads to unnecessary and fraudulent Medicare or insurance payouts.

Substandard or unnecessary care

Some providers may intentionally provide substandard or insufficient care while continuing to bill for services that were either not rendered or were inadequately provided. Although some fraud happens without the patient ever knowing, this particular type of fraud is especially harmful as it can lead to patients receiving poor quality end-of-life care.

Overutilization of hospice services

This involves a hospice provider excessively prolonging care for patients who no longer need it, in order to maximize reimbursement. Providers may also falsify records to show higher utilization of services than actually occurred.

Hospice fraud harms patients, their families, and the overall health care system that we all rely on. 

It harm patients by denying them appropriate care or subjecting them to unnecessary treatments. For example, a patient who is placed on hospice without their knowledge could be removed from an organ transplant waiting list, or a cancer patient could be denied access to chemotherapy treatments. They can lead to subpar care, unnecessary suffering, and a lack of resources for patients who genuinely need them. They distort the purpose of hospice care, which should focus on providing compassionate, patient-centered care for those nearing the end of life.

These practices harm the financial integrity of the health care system. 

They also cost reputable hospice organizations significant amounts of money. “The ‘bad actors’ are costing the good providers a lot of resources, time, and money,” Cheryl Fried tells me. “We have had to bear the burden of increased costs, due to all of the increased regulatory scrutiny that has been going on since around 2005.”

Fortunately, hospice fraud is being examined more closely. Fried is happy to report that well-operated hospice organizations make up the majority of providers around the nation. Those organizations have asked the Centers for Medicare and Medicaid Services (CMS) for years to hold both incompetent and fraudulent actors accountable and are relieved that CMS is probing hospice providers more closely and taking action when fraud is discovered.

If you suspect hospice fraud, the Senior Medicare Patrol offers resources for reporting concerns. SMP is funded by the federal government to enable Medicare beneficiaries to help detect and report health care fraud and abuse. 

If you’re searching for the best hospice care provider for your family, Seniors Guide offers a checklist of considerations in researching hospice care providers:

Checklist for Finding Quality Hospice Care