Among the numerous tactics that unscrupulous hospices use to commit fraud, three are rising to the forefront.

Four states have garnered national attention as fraud hotbeds — Arizona, California, Nevada and Texas. These regions have seen swarms of new hospices emerging and receiving Medicare dollars. Numerous reports of unethical or illegal practices have surfaced, particularly among these new companies.

Despite the best efforts of regulators and law enforcement, hospice leaders are concerned that many bad actors are slipping through the cracks. One common practice among them is to keep their patient census low to avoid regulators’ attention, Judy Lund Person, principal of the consulting firm Lund Person and Associates, said at the Hospice News ELEVATE conference in Orlando, Florida.

“‘Flying low’ is probably one of the most important pieces of this,” Lund Person told Hospice News at the conference. “Providers who are flying low think that they can get away with whatever because they have less than 20 patients, or they have less than 50 patients.”

Among these providers, three principal tactics are emerging, according to Sheila Clark, president and CEO of the California Hospice and Palliative Care Association. These are dubbed, identity theft, “poor care/no care” and uninformed consent.

When it comes to identify theft, fraudulent hospices obtain patients’ information and enroll them in hospice without their knowledge or consent. These patients often experience denials or delays of necessary health care because, on paper at least, they are in hospice. Most of these patients are not terminally ill.

“A beneficiary’s Medicare card is worth more to a scammer than a credit card,” Clark told Hospice News at ELEVATE. “A hospice election shuts your benefits off, and these beneficiaries cannot get care that they need.”

In poor care/no care scenarios, scammers enroll patients in hospice and subsequently do not provide the necessary or required services, Clark said. Their clinicians don’t show up, or if they do, they deliver shoddy care, thereby causing greater suffering for patients and families.

Poor care/no care is the most commonly occurring type of fraud in the hotbed state of Texas, Viki Jingle, CEO of Community Hospice of Texas said at ELEVATE.

In some cases, these providers are telling patients that hospice does not cover durable medical equipment or medical supplies. In others, patients go for weeks without necessary medications to control their symptoms, including pain, according to Jingle. Many of these patients end up back in the hospital because they are receiving no help in the home.

Moreover, these practices tarnish the reputation of all hospices and leave families with a poor perception of what should be person-centered end-of-life care.

“We could have kept them comfortable at home. This is complete abuse of the program and a disservice to that family. Now is that family going to refer hospice again to any of their friends or neighbors or anybody who comes into contact? Absolutely not,” Jingle told Hospice News at ELEVATE. “Most families don’t know what they should be getting. So of course, they’re going to believe whatever they hear. They don’t know the difference. They don’t know what is involved in the hospice benefit.”

In cases of uninformed consent, patients are often deceived into enrolling in the hospice benefit without understanding what that means for them, including those who are not terminally ill. Scammers will lie or conceal information from patients about what they are signing, often targeting places where seniors congregate or even public places like grocery stores and physician offices.

Many of these scammers will offer patients goods or compensation if they enroll in hospice.

“The big thing now is they give you shoes. They give you free shoes,” Clark said. “They give manicures, pedicures, lawn care. ‘Just sign here. You’ll get all this great stuff.’ And what they’re doing is they’re signing their consent form that says they are on hospice.”