Hospice Allegedly Knowingly Billed Medicare for Ineligible Patients
WASHINGTON - October 02, 2015 - 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, the Department of Justice announced today. Guardian is a for-profit hospice which provides hospice services in Atlanta.
“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.”
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 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 alleged that Guardian submitted or caused the submission of false claims for hospice care for patients who Guardian knew were not terminally ill. Specifically, the United States contended 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.
“Medicare payments to hospices are increasing every year,” said U.S. Attorney John A. Horn of the Northern District of Georgia. “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.”
“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 (HHS-OIG). “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.”
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.
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 $25.1 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.
This matter was investigated by the Civil Division’s Commercial Litigation Branch, the U.S. Attorney’s Office of the Northern District of Georgia, the FBI and HHS-OIG. The claims resolved by the settlement are allegations only and there has been no determination of liability.
The lawsuit is captioned U.S. ex rel. Betts, et al. v. Texas Home Health of America, L.P., et al.,No. 1 12:CV-0412 (N.D. Ga.).
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