The U.S. Centers for Medicare & Medicaid Services (CMS) has issued a memo to accreditation bodies and state agencies advising surveyors to watch out for potential hospice fraud.
The memo directs surveyors to refer issues to CMS if they suspect fraudulent activity. These actions were spurred by a rash of fraudulent hospices that have emerged primarily in California, Texas, Nevada and Arizona.
“While the primary purpose of [state agencies and accreditation organization] surveys is to determine compliance with the Medicare Hospice CoPs, there are several elements of the survey process that can uncover concerns that would necessitate a referral to CMS for potential fraud,” CMS indicated in the memo.
CMS has “encouraged” state agencies to refer hospices for enforcement remedies when deemed appropriate. The agencies can also review accreditation organization findings and, if serious issues are identified, conduct a validation survey to determine whether the hospice has taken corrective action.
While the memo does not ask surveyors to make determinations about potential fraud, it does give them a recourse for instances in which they have suspicions, according to Matt Wolfe, shareholder with the law firm Baker, Donelson, Bearman, Caldwell & Berkowitz, PC.
“It’s a very tangible, specific way to address concerns about bad actors that are already in the market, that are already operating hospices. Surveyors are going out there and actually surveying these hospices. But the challenge that they have is what do you do when you identify something that may not actually be fraudulent, but it certainly looks like fraudulent activity,” Wolfe told Hospice News. “This empowers those surveyors to both identify it and then to refer it to the appropriate law enforcement agencies.”
Possible enforcement remedies include suspension of payments for new admissions, civil monetary penalties, temporary management of the hospice, directed in-service training and plans of correction and termination from the Medicare program.
Investigations have shown that potentially hundreds of newly licensed hospices have bilked Medicare of millions of dollars during the past several years, all while providing egregiously poor care or none at all. Some of these providers engaged in referral kickback schemes, enrolled patients who were not eligible for hospice and lied to them about being terminally ill.
In some instances, multiple hospices have been operating out of the same address without a corresponding increase in the population of eligible patients. Some individuals also hold management positions at several of these hospices simultaneously.
According to the memo, surveyors should also be cognizant of potential unapproved changes in ownership or location, which are often associated with fraud. CMS said that reviewing certain documents and information that identify key managers, services and locations is “essential.”
The CMS document also emphasizes that surveyors should look beyond examining medical records and ensure they are observing patient care, Alissa Fleming, shareholder with Baker, Donelson, Bearman, Caldwell & Berkowitz, PC, told Hospice News.
“They are making home visits, observing the delivery of care in different environments. So that’s where you know there would be the opportunity to obtain information outside of the medical record,” Fleming said. “CMS is trying to increase awareness of conduct that may potentially be evidence of or suggestive of fraud and abuse. [Surveyors] are being given tools to identify behavior, conduct, patterns and practices that may be a sign of suspicious behavior.”
