Guardian Hospice pays $3 million to resolve Medicare Claims – At the Core Unethical Behavior?

Hospice – word that for most means care, compassion, comfort and dignity.  When you ask the majority of their opinion of “Hospice” the opinion is favorable!  Yet, not everyone will make the right ethical decisions when faced with temptation to financially succeed or survive.  That is apparently true when it comes to Guardian Hospice of Georgia.

The United States Attorney’s Office for the Northern District of Georgia announced that Guardian Hospice of Georgia, LLC, Guardian Home Care Holdings, Inc., and AccentCare, Inc., (collectively Guardian) agreed to pay $3 million to resolve allegations that Guardian knowingly submitted false claims to the Medicare program for hospice patients who were not terminally ill. Guardian is a for-profit hospice that provides hospice services in the Atlanta, Georgia, area.

“Medicare payments to hospices are increasing every year,” said U.S. Attorney John Horn. “In order to preserve Medicare funds for services patients truly need, we will continue to pursue hospice providers who abuse the Medicare hospice benefit by billing Medicare for the care of patients who are not terminally ill.”

““The Medicare hospice benefit is intended to provide comfort and care to patients nearing the end of life,” said Principal Deputy Assistant Attorney General Benjamin C. Mizer, head of the Justice Department’s Civil Division.  “We will continue to aggressively pursue companies that abuse the Medicare hospice benefit to improperly inflate their profits.”

“Hospice care is only medically appropriate – and reimbursed by Medicare – for terminally ill patients who are in the last months of their lives,” said Special Agent in Charge Derrick L. Jackson of the U.S. Department of Health and Human Services-Office of Inspector General.  “We will continue to vigorously investigate health care companies that put their own profits above their duty to give appropriate medical care to their patients and bill Medicare only for legitimate health care services.”

What Medicare pay for with Hospice?

The Medicare hospice benefit is available for patients who elect palliative treatment (medical care focused on providing patients with relief from pain, symptoms, or stress) for a terminal illness and who have a life expectancy of six months or less if their illness runs its normal course. Before billing Medicare, a hospice provider is obligated to comply with Medicare requirements and ensure that patients who are foregoing curative care are in need of end of life care.

The government alleges that Guardian submitted or caused the submission of false claims for hospice care for patients who Guardian knew were not terminally ill. These claims were submitted for services provided between December 1, 2009 and March 31, 2012. Specifically, the United States contends that Guardian’s business practices contributed to its submission of claims for patients who did not have a terminal prognosis of six months or less, including failing to properly train its staff and medical directors on the hospice eligibility criteria, setting aggressive targets to recruit and enroll patients, and failing to properly oversee the Atlanta hospice.

For Profit vs Not For Profit

While I cannot speak for Guardian…I can speak for what I witnessed with my wife as an employee of Hospices – both for profit and not for profit.  While employed at the non profit there was a desire to serve and because it was regulated (generally one hospice per county) there was little abuse (if any) and families loved the service they received.

Then we moved to Dallas/Fort Worth.  In Texas Hospices could be either for or not for profit.  In the Fort Worth market (at the time 2006) there we 71 hospices that were cut throat employing unconventional methods to secure customers and pay doctors off for referrals (if the doctors weren’t the silent owners of the hospices themselves).  The for profit market was dramatically different and if that had been her first experience with them (hospices) she would have quit.  The competition for business and unethical practices used were nauseating.

What about Guardian?

The settlement resolves allegations filed by Rose Betts and Jennifer Williams, former employees of Guardian, under the qui tam or whistleblower provisions of the False Claims Act, which authorize private parties to sue for false claims on behalf of the United States and share in the recovery. Ms. Betts and Ms. Williams will receive approximately $510,000. The lawsuit was filed in the Northern District of Georgia and is captioned U.S. ex rel. Betts v. Texas Home Health of America, L.P., No. 12-cv-0412.

Bravo for the Whistleblower!

This settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by the Attorney General and the Secretary of Health and Human Services. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered a total of more than $25.14 billion through False Claims Act cases, with more than $16.1 billion of that amount recovered in cases involving fraud against federal health care programs.

The claims resolved by the settlement are allegations only, and there has been no determination of liability.  Of course not, but the payment of $3 million speaks volumes.  The question now is how will this change Guardian’s business practices moving forward?

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