Attorney - Hospice Fraud - A reveal For Employees, Whistleblowers, Attorneys, Lawyers and Law FirmsGood evening. Yesterday, I learned about Attorney - Hospice Fraud - A reveal For Employees, Whistleblowers, Attorneys, Lawyers and Law Firms. Which may be very helpful in my experience and you. |
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Hospice fraud in South Carolina and the United States is an addition qoute as the whole of hospice patients has exploded over the past few years. From 2004 to 2008, the whole of patients receiving hospice care in the United States grew approximately 40% to nearly 1.5 million, and of the 2.5 million habitancy who died in 2008, nearly one million were hospice patients. The spectacular, majority of habitancy receiving hospice care receive federal benefits from the federal government through the Medicare or Medicaid programs. The health care providers who provide hospice services traditionally enroll in the Medicare and Medicaid programs in order to qualify to receive payments under these government programs for services rendered to Medicare and Medicaid eligible patients. What I said. It shouldn't be the conclusion that the actual about Attorney. You check out this article for home elevators a person need to know is Attorney.AttorneyWhile most hospice health care organizations provide acceptable and ethical rehabilitation for their hospice patients, because hospice eligibility under Medicare and Medicaid involves clinical judgments which may follow in the payments of large sums of money from the federal government, there are colossal opportunities for fraudulent practices and false billing claims by unscrupulous hospice care providers. As up-to-date federal hospice fraud compulsion actions have demonstrated, the whole of health care clubs and individuals who are willing to try to defraud the Medicare and Medicaid hospice benefits programs is on the rise. A up-to-date example of hospice fraud animated a South Carolina hospice is Southern Care, Inc., a hospice enterprise that in 2009 paid .7 million to settle an Fca case. The defendant operated hospices in 14 other states, too, along with Alabama, Georgia, Indiana, Iowa, Kansas, Louisiana, Michigan, Mississippi, Missouri, Ohio, Pennsylvania, Texas, Virginia and Wisconsin. The alleged frauds were that patients were not eligible for hospice, to wit, were not terminally ill, lack of documentation of final illnesses, and that the enterprise marketed to possible patients with the promise of free medications, supplies, and the provision of home health aides. Southern Care also entered into a 5-year Corporate Integrity bargain with the Oig as part of the settlement. The qui tam relators received approximately million. Understanding the Consequences of Hospice Fraud and Whistleblower Actions U.S. And South Carolina consumers, along with hospice patients and their family members, and health care employees who are employed in the hospice industry, as well as their Sc lawyers and attorneys, should acquaint themselves with the basics of the hospice care industry, hospice eligibility under the Medicare and Medicaid programs, and hospice fraud schemes that have advanced across the country. Consumers need to protect themselves from unethical hospice providers, and hospice employees need to guard against knowingly or unwittingly participating in health care fraud against the federal government because they may branch themselves to executive sanctions, along with lengthy exclusions from working in an club which receives federal funds, colossal civil monetary penalties and fines, and criminal sanctions, along with incarceration. When a hospice worker discovers fraudulent escort animated Medicare or Medicaid billings or claims, the worker should not share in such behavior, and it is imperative that the unlawful escort be reported to law compulsion and/or regulatory authorities. Not only does reporting such fraudulent Medicare or Medicaid practices shield the hospice worker from exposure to the foregoing administrative, civil and criminal sanctions, but hospice fraud whistleblowers may benefit financially under the recompense provisions of the federal False Claims Act, 31 U.S.C. §§ 3729-3732, by bringing false claims suits, also known as qui tam or whistleblower suits, against their employers on profit of the United States. Types of Hospice Care Services Hospice care is a type of health care aid for patients who are terminally ill. Hospices also provide reserve services for the families of terminally ill patients. This care includes physical care and counseling. Hospice care is ordinarily provided by a collective branch or underground enterprise beloved by Medicare and Medicaid. Hospice care is available for all age groups, along with children, adults, and the elderly who are in the final stages of life. The purpose of hospice is to provide care for the terminally ill patient and his or her family and not to cure the final illness. If a patient qualifies for hospice care, the patient can receive medical and reserve services, along with nursing care, medical collective services, doctor services, counseling, homemaker services, and other types of services. The hospice patient will have a team of doctors, nurses, home health aides, collective workers, counselors and trained volunteers to help the patient and his or her family members cope with the symptoms and consequences of the final illness. While many hospice patients and their families can receive hospice care in the ease of their home, if the hospice patient's health deteriorates, the patient can be transferred to a hospice facility, hospital, or nursing home to receive hospice care. Hospice Care Statistics The whole of days that a patient receives hospice care is often referenced as the "length of stay" or "length of service." The length of aid is dependent on a whole of dissimilar factors, along with but not small to, the type and stage of the disease, the potential of and passage to health care providers before the hospice referral, and the timing of the hospice referral. In 2008, the midpoint length of stay for hospice patients was about 21 days, the midpoint length of stay was about 69 days, approximately 35% of hospice patients died or were discharged within 7 days of the hospice referral, and only about 12% of hospice patients survived longer than 180 days. Most hospice care patients receive hospice care in underground homes (40%). Other locations where hospice services are provided are nursing homes (22%), residential facilities (6%), hospice patient facilities (21%), and acute care hospitals (10%). Hospice patients are generally the elderly, and hospice age group percentages are 34 years or less (1%), 35 - 64 years (16%), 65 - 74 years (16%), 75 - 84 years (29%), and over 85 years (38%). As for the final illness resulting in a hospice referral, cancer is the prognosis for approximately 40% of hospice patients, followed by debility unspecified (15%), heart disease (12%), dementia (11%), lung disease (8%), stroke (4%) and kidney disease (3%). Medicare pays the great majority of hospice care expenses (84%), followed by underground assurance (8%), Medicaid (5%), charity care (1%) and self pay (1%). As of 2008, there were approximately 4,700 locations which were providing hospice care in the United States, which represented about a 50% increase over ten years. There were about 3,700 clubs and organizations which were providing hospice services in the United States. About half of the hospice care providers in the United States are for-profit organizations, and about half are non-profit organizations.
In 1965, Congress established the Medicare schedule to provide health assurance for the elderly and disabled. Payments from the Medicare schedule arise from the Medicare Trust fund, which is funded by government contributions and through payroll deductions from American workers. The Centers for Medicare and Medicaid Services (Cms), previously known as the health Care Financing supervision (Hcfa), is the federal branch within the United States branch of health and Human Services (Hhs) that administers the Medicare schedule and works in partnership with state governments to administer Medicaid. In 2007, Cms reorganized its ten geography-based field offices to a Consortia buildings based on the agency's key lines of business: Medicare health plans, Medicare financial management, Medicare fee for aid operations, Medicaid and children's health, observe & certification and potential improvement. The Cms consortia consist of the following: • Consortium for Medicare health Plans Operations
Each consortium is led by a Consortium Administrator (Ca) who serves as the Cms's national focal point in the field for their enterprise line. Each Ca is responsible for consistent implementation of Cms programs, course and advice across all ten regions for matters pertaining to their enterprise line. In addition to accountability for a enterprise line, each Ca also serves as the Agency's senior supervision valid for two or three Regional Offices (Ros), representing the Cms Administrator in external matters and overseeing executive operations. Much of the daily supervision and performance of the Medicare schedule is managed through underground assurance clubs that compact with the Government. These underground assurance companies, sometimes called "Medicare Carriers" or "Fiscal Intermediaries," are expensed with and responsible for accepting Medicare claims, determining coverage, and manufacture payments from the Medicare Trust Fund. These carriers, along with Palmetto Government Benefits Administrators (hereinafter "Pgba"), a branch of Blue Cross and Blue Shield of South Carolina, operate pursuant to 42 U.S.C. §§ 1395h and 1395u and rely on the good faith and just representations of health care providers when processing claims. Over the past forty years, the Medicare schedule has enabled the elderly and disabled to collect necessary medical services from medical providers throughout the United States. necessary to the success of the Medicare schedule is the underlying view that health care providers accurately and absolutely submit claims and bills to the Medicare Trust Fund only for those medical treatments or services that are legitimate, reasonable and medically necessary, in full compliance with all laws, regulations, rules, and conditions of participation, and, further, that medical providers not take benefit of their elderly and disabled patients. The Medicaid schedule is available only to distinct low-income individuals and families who must meet eligibility requirements set forth by federal and state law. Each state sets its own guidelines about eligibility and services. Although administered by individual states, the Medicaid schedule is funded primarily by the federal government. Medicaid does not pay money to patients; rather, it sends payments directly to the patient's health care providers. Like Medicare, the Medicaid schedule depends on health care providers to accurately and absolutely submit claims and bills to schedule administrators only for those medical treatments or services that are legitimate, reasonable and medically necessary, in full compliance with all laws, regulations, rules, and conditions of participation, and, further, that medical providers not take benefit of their indigent patients. Medicare & Medicaid Hospice Laws Which work on Sc Hospices Hospice fraud occurs when hospice organizations, by and through their employees, agents and owners, knowingly violate the terms and conditions of the applicable Medicare and Medicaid hospice statutes, regulations, rules and conditions of participation. In order to be able to identify hospice fraud, hospices, hospice patients, hospice employees and their attorneys and lawyers must know the Medicare laws and requirements relating to hospice care benefits. Medicare's two main sources of authorization for hospice benefits are found in the collective security Act and the U.S. Code of Federal Regulations. The statutory provisions are primarily found at 42 U.S.C. §§ 1395d, 1395e, 1395f(a)(7), 1395x(d)(d), and 1395y, and the regulatory provisions are found at 42 C.F.R. Part 418. To be eligible for Medicare benefits for hospice care, the patient must be eligible for Medicare Part A and be terminally ill. 42 C.F.R. § 418.20. final illness is established when "the individual has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its general course." 42 C.F.R. § 418.3; 42 U.S.C. § 1395x(d)(d)(3). The patient's doctor and the medical director of the hospice must warrant in writing that the patient is "terminally ill." 42 U.S.C. § 1395f(a)(7); 42 C.F.R. § 418.20. After a patient's introductory certification, Medicare provides for two ninety-day benefit periods followed by an unlimited whole of sixty-day benefit periods. 42 U.S.C. § 1395d(a)(4). At the end of each ninety- or sixty-day period, the patient can be re-certified only if at that time he or she has less than six months to live if the illness runs its general course. 42 U.S.C. § 1395f(a)(7)(A). The written certification and re-certifications must be maintained in the patient's medical records. 42 C.F.R. § 418.23. A written plan of care must be established for each patient setting forth the types of hospice care services the patient is scheduled to receive, 42 U.S.C. § 1395f(a)(7)(B), and the hospice care has to be provided in accordance with such plan of care. 42 U.S.C. § 1395f(a)(7)(C); 42 C.F.R. § 418.56. Clinical records for each hospice patient must be maintained by the hospice, along with plan of care, assessments, clinical notes, signed observation of election, patient responses to medication and therapy, doctor certifications and re-certifications, outcome data, expand directives and doctor orders. 42 C.F.R. § 418.104. The hospice must collect a written observation of determination from the patient to elect to receive Medicare hospice benefits. 42 C.F.R. § 418.24. Importantly, once a patient has elected to receive hospice care benefits, the patient waives Medicare benefits for medical rehabilitation for the final disease upon which is the admitting diagnosis. 42 C.F.R. § 418.24(d). The hospice must prescription an Interdisciplinary Group (Idg) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing final illness and bereavement. 42 C.F.R. § 418.56. The Idg members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. A registered nurse that is a member of the Idg must be designated to provide coordination of care and to ensure continuous assessment of each patient's and family's needs and implementation of the interdisciplinary plan of care. The interdisciplinary group must include, but is not small to, the following considerable and competent professionals: (i) A doctor of rehabilitation or osteopathy (who is an worker or under compact with the hospice); (ii) A registered nurse; (iii) A collective worker; and, (iv) A pastoral or other counselor. 42 C.F.R. § 418.56. The Medicare hospice regulations, at 42 C.F.R. § 418.200, summarize the requirements for hospice coverage in pertinent part as follows: To be covered, hospice services must meet the following requirements. They must be reasonable and necessary for the palliation and supervision of the final illness as well as related conditions. The individual must elect hospice care in accordance with §418.24. A plan of care must be established and periodically reviewed by the attending physician, the medical director, and the interdisciplinary group of the hospice schedule as set forth in §418.56. That plan of care must be established before hospice care is provided. The services provided must be consistent with the plan of care. A certification that the individual is terminally ill must be completed as set forth in section §418.22. The collective security Act, at 42 U.S.C. § 1395y(a), limits Medicare hospice benefits, providing in pertinent part as follows: "Notwithstanding any other provision of this title, no cost may be made under part A or part B for any expenses incurred for items or services-... (C) in the case of hospice care, which are not reasonable and necessary for the palliation or supervision of final illness...." 42 C.F.R. § 418.50 (hospice care must be "reasonable and necessary for the palliation and supervision of final illness"). Palliative care is defined in the regulations as "patient and family-centered care that optimizes potential of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, passage to information, and choice." 42 C.F.R. § 418.3. Medicare pays hospice agencies a daily rate for each day a beneficiary is enrolled in the hospice benefit and receives hospice care. The daily payments are made regardless of the whole of services furnished on a given day and are intended to cover costs that the hospice incurs in furnishing services identified in the patient's plan of care. There are four levels of payments which are made based on the whole of care required to meet beneficiary and family needs. 42 C.F.R. § 418.302; Cms Hospice Fact Sheet, November 2009. These four levels, and the corresponding 2010 daily rates, are as follows: disposition home care (2.91); continuous home care (4.10); patient respite care (7.83); and, general patient care (5.74). The mixture annual cap per patient in 2009 was ,014.50. This cap is determined by adjusting the primary hospice patient cap of ,500, set in 1984, by the consumer Price Index. See Cms Internet-Only hand-operated 100-04, part 11, section 80.2; 42 U.S.C. § 1395f(i); 42 C.F.R. § 418.309. The Medicare Claims Processing Manual, at part 11 - Processing Hospice Claims, in Section 80.2, entitled "Cap on farranging Hospice Reimbursement," provides in pertinent part as follows: "Any payments in excess of the cap must be refunded by the hospice." Hospice patients are responsible for Medicare co-insurance payments for drugs and respite care, and the hospice may payment the patient for these co-insurance payments. However, the co-insurance payments for drugs are small to the lesser of or 5% of the cost of the drugs to the hospice, and the co-insurance payments for respite care are generally 5% of the cost made by Medicare for such services. 42 C.F.R. § 418.400. The Medicare and Medicaid programs require institutional health care providers, along with hospice organizations, to file an enrollment application in order to qualify to receive the programs' benefits. As part of these enrollment applications, the hospice providers warrant that they will comply with Medicare and Medicaid laws, regulations, and schedule instructions, and added warrant that they understand that cost of a claim by Medicare and Medicaid is conditioned upon the claim and underlying transaction complying with such schedule laws and requirements. The Medicare Enrollment Application which hospice providers must execute, Form Cms-855A, states in part as follows: "I agree to abide by the Medicare laws, regulations and schedule instructions that apply to this provider. The Medicare laws, regulations, and schedule instructions are available through the Medicare contractor. I understand that cost of a claim by Medicare is conditioned upon the claim and the underlying transaction complying with such laws, regulations, and schedule instructions (including, but not small to, the Federal Aks and Stark laws), and on the provider's compliance with all applicable conditions of participation in Medicare." Hospices are generally required to bill Medicare on a monthly basis. See the Medicare Claims Processing Manual, at part 11 - Processing Hospice Claims, in Section 90 - Frequency of Billing. Hospices generally file their hospice Medicare claims with their Fiscal Intermediary or Medicare Carrier pursuant to the Cms Claims hand-operated Form Cms 1450 (sometime also called a Form Ub-04 or Form Ub-92), either in paper or electronic form. These claim forms include representations and certifications which state in pertinent part that: (1) misrepresentations or falsifications of necessary information may serve as the basis for civil monetary penalties and criminal convictions; (2) submission of the claim constitutes certification that the billing information is true, accurate and complete; (3) the submitter did not knowingly or recklessly disregard or misrepresent or conceal material facts; (4) all required doctor certifications and re-certifications are on file; (5) all required patient signatures are on file; and, (6) for Medicaid purposes, the submitter understands that because cost and pleasure of this claim will be from Federal and State funds, any false statements, documents, or concealment of a material fact are branch to prosecution under applicable Federal or State Laws. Hospices must also file with Cms an annual cost and data description of Medicare payments received. 42 U.S.C. § 1395f(i)(3); 42 U.S.C. § 1395x(d)(d)(4). The annual hospice cost and data reports, Form Cms 1984-99, include representations and certifications which state in pertinent part that: (1) misrepresentations or falsifications of information contained in the cost description may be punishable by criminal, civil and executive actions, along with fines and/or imprisonment; (2) if any services identified in the description were the goods of a direct or indirect kickback or were otherwise illegal, then criminal, civil and executive actions may result, along with fines and/or imprisonment; (3) the description is a true, accurate and complete statement prepared from the books and records of the supplier in accordance with applicable instructions, except as noted; and, (4) the signing officer is well-known with the laws and regulations about the provision of health care services and that the services identified in this cost description were provided in compliance with such laws and regulations. Hospice Anti-Fraud compulsion Statutes There are a whole of federal criminal, civil and executive compulsion provisions set forth in the Medicare statutes which are aimed at preventing fraudulent conduct, along with hospice fraud, and which help verbalize schedule integrity and compliance. Some of the more leading compulsion provisions of the Medicare statutes include the following: 42 U.S.C. § 1320a-7b (Criminal fraud and anti-kickback penalties); 42 U.S.C. § 1320a-7a and 42 U.S.C. § 1320a-8 (Civil monetary penalties for fraud); 42 U.S.C. § 1320a-7 (Administrative exclusions from participation in Medicare/Medicaid programs for fraud); 42 U.S.C. § 1320a-4 (Administrative subpoena power for the Comptroller General). Other criminal compulsion provisions which are used to combat Medicare and Medicaid fraud, along with hospice fraud, include the following: 18 U.S.C. § 1347 (General health care fraud criminal statute); 21 U.S.C. §§ 353, 333 (Prescription Drug Marketing Act); 18 U.S.C. § 669 (Theft or Embezzlement in relationship with health Care); 18 U.S.C. § 1035 (False statements relating to health Care); 18 U.S.C. § 2 (Aiding and Abetting); 18 U.S.C. § 3 (Accessory after the Fact); 18 U.S.C. § 4 (Misprision of a Felony); 18 U.S.C. § 286 (Conspiracy to defraud the Government with respect to Claims); 18 U.S.C. § 287 (False, Fictitious or Fraudulent Claims); 18 U.S.C. § 371 (Criminal Conspiracy); 18 U.S.C. § 1001 (False Statements); 18 U.S.C. § 1341 (Mail Fraud); 18 U.S.C. § 1343 (Wire Fraud); 18 U.S.C. § 1956 (Money Laundering); 18 U.S.C. § 1957 (Money Laundering); and, 18 U.S.C. § 1964 (Racketeer Influenced and Corrupt Organizations ("Rico")). The False Claims Act (Fca) Hospice fraud whistleblowers may benefit financially under the recompense provisions of the federal False Claims Act, 31 U.S.C. §§ 3729-3732, by bringing false claims suits, also known as qui tam or whistleblower suits, against their employers on profit of the United States. The plaintiff in a hospice fraud whistleblower suit is also known as a relator. The most common Fca provisions upon which hospice fraud qui tam or whistleblower relators rely are found in 31 U.S.C. § 3729: (A) knowingly presents, or causes to be presented, a false or fraudulent claim for cost or approval; (B) knowingly makes, uses, or causes to be made or used, a false description or statement material to a false or fraudulent claim; (C) conspires to commit a violation of subparagraph (A), (B), (D), (E), (F), or (G);..., and, (G) knowingly makes, uses, or causes to be made or used, a false description or statement material to an compulsion to pay or forward money or property to the Government, or knowingly conceals or knowingly and improperly avoids or decreases an compulsion to pay or forward money or property to the Government.... There is no requirement to prove specific intent to defraud. Rather, it is only necessary to prove actual knowledge of the false claims, false statements, or false records, or the defendant's deliberate indifference or reckless disregard of the truth or falsity of the information. 31 U.S.C. § 3729(b). The Fca anti-retaliation provision protects the hospice whistleblower from retaliation from the hospice when the worker (or a contractor) "is discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of employment" for taking activity to try to stop the fraudulent activity. 31 U.S.C. § 3730(h). A hospice employee's relief includes reinstatement, 2 times the whole of back pay, interest on the back pay, and payment for any extra damages sustained as a follow of the discrimination or retaliation, along with litigation costs and reasonable attorneys' fees. A Sc hospice fraud Fca whistleblower would initially file a disclosure statement, complaint and supporting documents with the U.S. Attorney's Office in Columbia, South Carolina, and the Us Attorney General. After the disclosures are filed, a federal court complaint can be filed. The Sc branch where the frauds occurred, the relator's residence, and the defendant residence, will settle which branch the case will be assigned. There are eleven federal court divisions in South Carolina. Once the case has been filed, the government has 60 days to settle either or not to intervene. During this time, federal government investigators placed in South Carolina will study the claims. If the case complex Medicaid, Sc Medicaid fraud unit investigators will likely become complex as well. If the government intervenes in the case, the U.S. Attorney for South Carolina is ordinarily the lead attorney. If the government does not intervene, the relator's Sc attorney will prosecute the case. In South Carolina, expect a qui tam case to take one to two years to get to trial. Tips on Recognizing Hospice Fraud Schemes The Hhs Office of Inspector general (Oig) has issued extra Fraud Alerts for fraudulent and abusive practices of hospices. U.S. And South Carolina hospices, patients, hospice employees and whistleblowers, their attorneys and lawyers, should be well-known with these hospice fraud practices. Tips on recognizing hospice frauds in South Carolina and the U.S. Are: • A hospice offering free goods or goods at below shop value to induce a nursing home to refer patients to the hospice.
Recent Hospice Fraud compulsion Cases The Doj and U.S. Attorney's Offices have been active in enforcing hospice fraud cases. In 2009, Kaiser Foundation Hospitals placed an Fca lawsuit by paying .8 million to the federal government. The defendant assertedly failed to collect written certifications of final illness for a whole of its patients. In 2006, Odyssey Healthcare, a national hospice provider, paid .9 million to settle a qui tam suit for false claims under the Fca. The hospice fraud allegations were generally that Odyssey billed Medicare for providing hospice care to patients when they were not terminally ill and ineligible for Medicare hospice benefits. A Corporate Integrity bargain was also a part of the settlement. The hospice fraud qui tam relator received .3 million for blowing the whistle on the defendant. In 2005, Faith Hospice, Inc., placed claims an Fca claim for 0,000. The hospice fraud allegations were generally that Faith Hospice billed Medicare for providing hospice care to patients more than half of whom were not terminally ill. In 2005, Home Hospice of North Texas placed an Fca claim for 0,000 about allegations of fraudulently billing Medicare for ineligible hospice patients. In 2000, Michigan osteopath Donald Dreyfuss, who pleaded guilty to criminal fraud charges, along with violation of the Aks for receiving illegal kickbacks from a hospice for recommending the hospice to the staff of his nursing home, placed an Fca suit for million. Conclusion Hospice fraud is a growing qoute in South Carolina and throughout the United States. South Carolina hospice patients, hospice employees, and their Sc lawyers and attorneys, should be well-known with the basics of the hospice care industry, hospice eligibility under the Medicare and Medicaid programs, and typical hospice fraud schemes. Hospice organizations should take steps to ensure full compliance with Medicare/Medicaid hospice billing requirements to avoid hospice fraud allegations and Fca litigation. © 2010 Joseph P. Griffith, Jr. I hope you will get new knowledge about Attorney. Where you may offer utilization in your daily life. And just remember, your reaction is passed about Attorney. Read more.. Hospice Fraud - A reveal For Employees, Whistleblowers, Attorneys, Lawyers and Law Firms. |
Hospice Fraud - A reveal For Employees, Whistleblowers, Attorneys, Lawyers and Law Firms
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