Literature Review

3 strategies for hospice GIP compliance Hospice News; by Jim Parker; 10/21/24 Utilization of the general inpatient level of care (GIP) is frequently the subject of audits by Medicare Administrative Contractors (MACs), and avoiding or responding to that scrutiny requires strict compliance to a complex web of rules. Audits are becoming more frequent in the hospice space, and GIP is an increasing focus, including ​for the most common types — Supplemental Medical Review Contractor (SMRC) and Targeted Probe and Educate (TPE). In a survey earlier this year, more than half of hospice providers reported having undergone multiple types of audits within a six-month period. ... In addition to these routine MAC audits, the U.S. Department of Health and Human Services Office of the Inspector General (GIP) has been performing a national audit of GIP utilization, as well as an additional investigation into management of the associated payment cap. The inpatient cap limits the number of days of inpatient care for which Medicare will pay to 20% of a hospice’s total Medicare patient care days, according to OIG. If GIP billing exceeds that metric, the hospice must refund those payments to Medicare.

Hospice fraud casts lengthening shadow over future of industryHospice News; by Holly Vossel; 10/11/24Fraudulent operators in the hospice space have misspent millions of Medicare dollars in recent years. This problem has become so severe that it is one of the defining issues facing the hospice industry, with providers and other industry stakeholders expressing concern about significant impacts to future payment, access, sustainability and utilization. This is the first of a two-part Hospice News series that examines the financial and operational pressures weighing on the minds of hospice providers amid instances of fraud, waste and abuse occurring in the industry.Notable mentions: Patrick Harrison, Senator Elizabeth Warren, MedPAC, Lauren Hunt.

CMS memo hints at what hospices can expect under Special Focus ProgramMcKnight's Home Care; by Adam Healy; 10/8/24Hospices subjected to Special Focus Program (SFP) scrutiny will undergo frequent surveys, and noncompliant providers may face termination from the Medicare program, according to the Centers for Medicare & Medicaid Services. Under the SFP, hospices will receive surveys no less than every six months, and follow-ups may be needed, CMS said in a memo to state hospice survey agencies. Hospices that are found to have condition-level deficiencies will be required to complete appropriate enforcement remedies, which include suspension of payment, civil money penalties, directed plans of correction, directed in-service training or termination, according to CMS’ state operations manual. Hospices that have completed two SFP surveys within 18 months, have zero uncorrected condition-level deficiencies and zero pending immediate jeopardy or condition-level complaints may graduate from the SFP, CMS said. However, any hospice that does not comply with all of CMS’ requirements within the necessary timeframes may be considered for termination.

Hospice ‘license flipping’ still plagues sector, though regulations help Hospice News; by Jim Parker; 10/3/24  “Shady” brokers allegedly continue to facilitate “license flipping” among fraudulent hospices, though new regulations have started bearing down on the practice. Soon after obtaining them, or before regulators can act on alleged malfeasance, according to several industry sources who spoke with Hospice News. The practice appears to stem from a rash of newly licensed hospices that have emerged in California, Nevada, Texas and Arizona – states identified by federal watchdogs as hotspots for hospice fraud. Many of these sales involve certain brokers who move the licenses between owners. “There’s a lot of shady people out there, and they put a high value on their agencies. Right now they’re selling like hot tamales from anywhere between $300,000 to $500,000 per license,” one former hospice leader told Hospice News on condition of anonymity. “They’re all done through the same brokers and the same people.”  

SNF, home health [and hospice] CEOs could be jailed over cybersecurity issues under new billMcKnight's Senior Living; by Kathleen Steele Gaivin; 9/30/24New legislation aimed at improving cybersecurity in healthcare could see leaders at skilled nursing facilities, home health agencies and hospices jailed if they lie about their cybersecurity precautions, according to one of its sponsors. Senate Finance Committee Chair Ron Wyden (D-OR) and Sen. Mark Warner (D-VA) announced the Health Infrastructure Security and Accountability Act on Thursday. The bill also covers other types of healthcare businesses. “The healthcare industry has some of the worst cybersecurity practices in the nation despite its critical importance to Americans’ well-being and privacy,” Wyden said. “These commonsense reforms, which include jail time for CEOs that lie to the government about their cybersecurity, will set a course to beef up cybersecurity among healthcare companies across the nation and stem the tide of cyberattacks that threaten to cripple the American healthcare system.”

Fighting ‘phantoms’: How fraud skews competition in the hospice market Hospice News; by Holly Vossel; 9/26/24 Fraudulent operators’ marketing strategies are morphing the competitive landscape, making it difficult for legitimate hospice providers to maintain visibility among patients and families. A mounting concern is that fraudsters stepping into the hospice industry have been implementing marketing and outreach practices that at times mirror strategies utilized by quality providers, according to Jeanne Chirico, president and CEO of the Hospice & Palliative Care Association of New York State (HPCANYS). This makes it difficult for referrals, patients and their families to discern the best end-of-life care option. Another significant concern is that the fraudulent actors may have deeper pockets compared to smaller or nonprofit hospices, allowing them to invest more heavily and saturate the market with their messaging. 

Telehealth bill for Medicare approved by House Panel Retirement Daily; by Retirement Daily; 9/21/24 House Ways and Means Committee on Sept. 18, 2024, passed the Preserving Telehealth, Hospital, and Ambulance Access Act by a vote of 41-0 after lawmakers raised concerns about the need for more guardrails and hospice recertification. The move sets up the legislation for passage by the full House later this year. The markup included objections by Democrats and Republicans to the high cost durable medical equipment and clinical diagnostics guardrails proposed in the bill, saying the provisions merely restate existing authorities of the Center for Medicare and Medicaid Services. The bill requires reports on DME and clinical diagnostics fraud which some lawmakers think have already been established and don’t need further study. Many lawmakers likewise expressed concern about the extension of hospice recertification via telehealth. Some lawmakers raised concern about fraud in the hospice program, which they say the telehealth requirement could let fester.

CVS' Oak Street Health pays $60M to settle kickback allegationsModern Healthcare; by Katherine Davis; 9/18/24Chicago-based healthcare firm Oak Street Health has agreed to pay $60 million to resolve allegations from the U.S. Department of Justice that it paid kickbacks to third-party insurance agents in exchange for recruiting seniors to Oak Street’s primary care clinics. The DOJ alleged in a statement today that Oak Street’s Client Awareness Program, designed to grow patient membership, had third-party insurance agents contacting seniors eligible for or enrolled in Medicare Advantage plans, seeking to recruit them to Oak Street locations.

Hospice fraud prevention toolkitCMS press release; 9/24People with Medicare should beware of scammers offering older Americans in-home perks, like free cooking, cleaning and home health services, while they are unknowingly being signed up for hospice services. The scammers then unlawfully bill Medicare for these services in your name. Criminals are using every avenue they can to sign people up including door-to-door visits, false advertising, phone, text and email. Hospice care is for people who are terminally ill and only the patient and doctor can make this serious decision about end-of-life care. This toolkit includes social media posts and a drop-in article to help educate beneficiaries and their loved ones on how to protect themselves against Medicare Hospice fraud.Publisher's note: Also see resources posted on the CMS Senior Medicare Patrol Hospice Fraud website.

CVS' Oak Street Health to pay $60M to settle Medicare Advantage kickback allegations Becker's Health IT; by Naomi Diaz; 9/19/24 CVS subsidiary Oak Street Health has agreed to pay $60 million to settle accusations that it violated the False Claims Act by offering kickbacks to third-party insurance agents in return for referring older adults to its primary care clinics. ... The settlement addresses allegations that, between September 2020 and December 2022, Oak Street Health knowingly submitted false claims to Medicare by offering illegal payments to agents, violating the Anti-Kickback Statute. CVS acquired Oak Street Health for $10.6 billion in May 2023. 

United States settles claims of durable medical equipment fraud against Wilmington physicianDOJ press release; 9/11/24WILMINGTON, Del. – U.S. Attorney David C. Weiss announced today that Dr. Vishal Patel, a Wilmington physician, has agreed to pay $1,080,000 to resolve allegations that he violated the False Claims Act by ordering medically unnecessary durable medical equipment for patients covered by Medicare and the Federal Employees Health Benefits Program (FEHBP). Between February 2018 and April 2019, Dr. Patel referred patients for more than 1750 orthotic devices, including wrist, shoulder, knee, ankle, and back braces. The United States alleges that Dr. Patel had no medical relationship with these patients and that the referrals were based on brief reviews of the patients’ medical charts, which failed to establish any legitimate medical justification for the devices. Medicare and FEHBP paid, on average, more than $400 for each device. Patient files were provided to Dr. Patel by RediDoc, LLC, a purported telemedicine company based in Phoenix, Arizona whose owners pleaded guilty to participation in a $64 million health care fraud conspiracy in May 2022.

Home health care company operators sentenced to prison in $5.5 million kickback scheme and tax evasionDOJ press release; 9/5/24A married Macomb County [MI] couple, Noli and Isabel Tcruz, both 68, were sentenced today to 6 years in prison and 38 months in prison, respectively, on health care fraud kickback conspiracy, tax evasion, and fraud charges, announced U.S. Attorney Dawn N. Ison. This follows the sentencings earlier this year of two doctors who had pled guilty to receiving kickbacks and bribes from the Tcruzes... The Tcruzes engaged in an approximately $5 million conspiracy to illegally pay kickbacks and bribes to acquire referrals for home health care for Medicare beneficiaries and refused to pay their income tax obligations for both -personal and business taxes. After their last home health company was shut down in February 2020, Noli Tcruz began engaging in Covid-19 program fraud, and used a family member’s identity and company to steal from and defraud the Small Business Administration and Health and Human Services out of more than $250,000 from pandemic assistance funds.

$83M fraud case against nursing home group may proceed, with no defendants excusedMcKnight's Long-Term Care News; by Jessica R. Towhey; 8/27/24A New York Supreme Court judge threw out all arguments from lawyers for an embattled group of nursing homes that sought to have charges dismissed in a case accusing the owners and operators of $83 million in Medicare and Medicaid fraud. Judge Melissa Crane ruled that the owners of Centers Health Care, along with numerous other individuals, did not make sufficient arguments for dropping charges of fraud, “saddling” nursing homes with “excessive debts,” colluding to pay “sham vendors,” and paying themselves “inflated” salaries.