Hospice Fraud: Terminal Prognosis Certification and Live Discharge
Hospice fraud centers on eligibility. Medicare covers hospice for patients with a life expectancy of six months or less if the illness runs its normal course. Enrolling patients who do not meet that standard, or billing general inpatient care that was not required, creates False Claims Act liability.
The certification is the claim
Hospice election requires a physician certification of terminal prognosis. Every benefit period requires recertification, and the medical record must support it.
Where a hospice recruits patients who are not terminally ill and obtains certifications that the record does not support, every day billed under that election is a false claim. The payment is per diem, so a single improper enrollment generates claims continuously.
The patterns enforcement looks for
Hospice cases have recognizable statistical signatures.
- Long lengths of stay well beyond six months without decline
- High live discharge rates, indicating patients who were never terminal
- Marketing to assisted living and nursing facilities for census rather than referral appropriateness
- General inpatient care billed where routine home care was appropriate
- Physicians certifying prognoses without examining the patient
- Documentation describing decline that the clinical record does not show
Live discharge is the tell
A patient discharged alive from hospice was, by definition, not in the last six months of life when enrolled, or improved. Some live discharge is normal and clinically appropriate.
A high rate is not. It indicates systematic enrollment of patients who did not qualify, and it is the metric that most often opens these investigations.
The human dimension
These cases carry a weight that billing cases usually do not. Enrolling a patient in hospice who is not dying can mean curative treatment is stopped.
Hospice nurses and social workers who report this are often motivated by that rather than by the award, and it is worth saying that the two are not in tension.
Frequently asked questions
What is the eligibility standard?
A life expectancy of six months or less if the terminal illness runs its normal course, certified by a physician and supported by the clinical record at each benefit period.
Patients sometimes live longer than expected. Is that fraud?
No. Prognosis is uncertain and outliving a prognosis is common. The issue is a pattern of enrollments the record never supported, and marketing aimed at census rather than eligibility.
What is general inpatient care fraud?
General inpatient is the highest hospice payment level, for symptom management that cannot be provided at home. Billing it where routine home care was appropriate is a common theory.
The attorneys who handle these cases
Related reading
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