Understanding Hospice Fraud and Common Allegations

Patients enter into hospice programs when they are dying. Hospice care is a program for end-of-life healthcare services, and a doctor must present a diagnosis that shows the individual is at the end of their life. During the services, they present the patient with services to keep them comfortable until they pass. The service providers offer comfort and counseling for the family to help them transition to the next step. With the healthcare services, there is a possibility of fraud and illegal actions that could cut the patient’s care short, even though the service provider is still receiving funds through the patient’s insurance coverage.

Understanding What Kickbacks Are

When investigating a hospice fraud allegation, the attorneys review billing records for the patient and assess what services the healthcare provider claimed to provide. A kickback is when the service provider offers financial incentives for a medical facility to refer or transfer a patient into the program when the individual isn’t dying. Essentially, the service provider gets paid for services they didn’t provide through the program, and the medical facility receives a payment to look the other way.

This could also link to another allegation of fraud, which is providing a false diagnosis. Under the circumstances, the doctor claims the patient has only one year to live when, in fact, the patient isn’t terminally ill. The diagnosis requires the service provider to discharge the patient from their care. However, the end-of-life services don’t discharge the patient, and they continue to receive payments through the patient’s medical coverage. This is another instance of fraud.

Whistleblowers and Legal Protection

Under federal laws, whistleblowers are protected against retaliation by employers and co-workers. With Medicare and end-of-life services fraud, the individual can present evidence showing that their employer or individuals working in the same company have committed fraud. Whistleblowers get immunity from prosecution according to the deal they make with a district attorney. These individuals could maintain their anonymity until the case goes to trial. This is often for their protection.

Common allegations of fraud could include coercing individuals to leave the program and transfer back to standard health services. The trick is to discharge the terminal patient to ensure that the insurance payments go to the medical facility instead of the end-of-life provider. Changing the dates on procedure billing after the patient enters the program as a terminal patient. Adjusting the maximum payout through Medicare gives the hospital more money when they weren’t supposed to exceed a specific amount of coverage.

How are the Home Health Services Paid?

Individuals who have terminal illnesses may choose to spend the remainder of their lives at home. However, they will need around-the-clock care to ensure they stay comfortable until they pass away. Individuals who need these services pay for the expenses through long-term disability insurance, healthcare savings plans, and healthcare insurance coverage.

Service providers have designated fees for all services. They bill the patient’s insurance according to the services a patient receives, medication costs, and additional equipment for the patient. When billing the insurer, the service provider cannot inflate their costs just because the insurer will pay more. The costs must remain consistent for all patients. However, the home health service provider may reduce rates for individuals with low incomes and no insurance.

If the service provider is suspected of fraud, an audit is conducted to find evidence of fraud. Keeping accurate records for all patients with itemized billing and explicit details about each healthcare service the patient receives could help the individual avoid a fraud charge. However, under the circumstances, the patient or their family would have to substantiate the healthcare provider’s claims.

What Could Happen if Convicted

The home health provider could face financial liabilities for each instance of healthcare fraud. If prosecuted, the prosecution will go through all patient records and identify each patient managed through the agency. If the defendant is found guilty, there are criminal penalties applied, too. The total number of criminal charges define how the individual could spend in prison and how hefty the fines are. When it comes to home health fraud, the state could impose a charge for each individual instance of fraud.

The Defendant Wasn’t Aware of the Fraudulent Acts

Typically, when a home health care agency is investigated, the investigators review the service provider according to what role workers played in the fraudulent acts. For example, one strategy for defending an individual against fraud is a lack of knowledge. For instance, the medical biller entered the details into the database according to the forms turned in by the medical staff. This individual is transferring information from the forms to the claims forms on the agency system.

As a defense, the individual wasn’t aware that the physicians or nursing staff added services the patient didn’t receive. When investigating fraud, investigators could exonerate the medical biller if the information on the physical forms matches what they added into the database. However, if the agency owner changed the database information, there would be a record of the owner signing into the system and altering the records.

Home health care and insurance fraud could originate with a healthcare provider. There are a number of instances that are fraudulent acts. Essentially, committing fraud involves signing up patients that didn’t qualify for end-of-life services or discharging the patients too soon. Any instance in which the service provider received funds for a service they didn’t provide is classified as fraud. Scammers inflate the cost of medical services to get more out of insurance providers such as Medicaid and Medicare. However, when it comes to formal charges, the defendant must have known of the actions, and they could have a viable defense if they weren’t the party that committed the crime. For example, whistleblowers who discover fraud are protected by applicable laws, and the government or state offers the protection. Reviewing healthcare and insurance fraud shows defendants what to expect if they are charged and what defense could apply to their cases.

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