The False Claims Act makes it illegal to bill the U.S. government under false pretenses — for instance, by seeking Medicare reimbursement for unqualified hospice treatment. The law provides a financial incentive for whistleblowers to report such wrongdoing by filing a lawsuit on behalf of taxpayers. This "qui tam" provision allows prevailing plaintiffs to receive up to 30% of the money returned to U.S. coffers.
If a whistleblower gets fired for reporting fraud, or suffers other retaliation, the FCA demands that the harm be reversed entirely: Successful plaintiffs can get their jobs back — and may get damages including attorney fees and payment for emotional distress.
As with all legal claims, deadlines are crucial. If you have been punished for drawing attention to shady behavior at a hospice, you must file a retaliation claim under the FCA within three years. The statute of limitations for the underlying fraud generally is six years under the FCA — or 10 years in a few situations. Other laws, including some relevant state laws, may demand faster action.
How are hospice whistleblowers rewarded?
As an inducement for people to expose fraud against programs such as Medicare, the False Claims Act allows whistleblowers to receive up to 30% of any money the U.S. government recovers as a result of their litigation. Since a large percentage of hospice care is funded by Medicare’s end-of-life benefit — and since the federal government faces a growing wave of hospice fraud — the FCA is a powerful incentive for hospice whistleblowers. Depending on your state, however, other rewards statutes may also apply.
How does hospice fraud work?
Medicare is a government health insurance program for older people. It includes a benefit for hospice care — end-of-life care that is intended to ease suffering, but not to cure any condition. This is sometimes called palliative care.
In order to receive Medicare’s hospice benefit, a patient should be certified with a condition that, in its normal course, is expected to end in death within six months. A minority of unethical hospices, however, accept older patients who don’t meet this standard — or, in some cases, who aren’t even terminally ill. As a result, they may collect benefits for months or years longer than intended.
Meanwhile the elderly patients, who often lack an effective representative and are already disoriented, may be kept docile via sedatives and painkillers. Because Medicare thinks they are terminally ill, it doesn’t cover any drugs that are intended to cure them.
Common types of hospice fraud
If you work in a hospice, or for a company that provides in-home hospice care, you may have witnessed some of these practices:
- False certification: To qualify for hospice benefits under Medicare, a patient normally should be certified by a doctor to have six months of life remaining. Some hospice providers may ignore this requirement, or may obtain a false certification.
- Kickbacks: Some hospices may offer money, gifts, or other favors to doctors who refer lucrative patients to their facilities.
- Billing fraud: Hospice providers may bill for services they did not deliver, such as licensed massage therapy, or for equipment or supplies that weren’t used; or they may bill for higher levels of care than they delivered, a practice known as upcoding.
- Fraudulent treatment plans: Hospice providers may falsify patient records to justify unneeded services such as stronger painkilling regimes — even if a patient is showing no discomfort.
- Self-referrals: Some doctors may have an ownership stake in a provider of hospice care, or a family member may have a stake. This is legal — but such doctors are not allowed to refer their patients to these hospice companies, because it is a conflict of interest.
- End of Life Fraud Billing: When hospice bills loved ones or family members to unnecessary treatments or medication as someone nears their death.
How do I report hospice fraud?
Low-level hospice fraud can be reported via StopMedicareFraud.gov, a joint Web site of the Department of Justice and the Department of Health and Human Services.
If you are a healthcare worker who knows about serious hospice fraud — or if you have faced retaliation in connection with such fraud — you may want to file a whistleblower lawsuit under the False Claims Act, a state equivalent, or both. There are strict standards for such suits: You must supply important information that the government doesn’t already know, for example, and you shouldn’t be a participant in the fraud yourself.
Blowing the whistle on hospice fraud isn’t a simple matter. If you would like to have an experienced law firm on your side, please contact us.