Benefit Bulletin: June 2016

Benefit Bulletin: June 2016

Can You Identify Medicare Fraud In This Story?

A few weeks after a 90-year old woman was moved into an assisted living facility, her daughter was surprised to be told that her mother was a good candidate for hospice.  The move to assisted living was only intended for help with her mother’s daily care, and her mother’s doctor said she wasn’t near the end of her life.  Yet, the daughter was told by the assisted living director, that going into hospice doesn’t mean that an individual is terminal, and that her mother would get more care at no additional cost.  In subsequent meetings with a hospice representative, the daughter was told her mother could get a new wheelchair and walker, even though her current wheelchair and walker were just fine, as well as a new bed, commode, and padded floor mats.

Hospice ordered the new equipment, including a breathing machine — which her mother had not needed before — and medication to ease a recurring backache.  Fearing that her mother was over - medicated, the daughter requested that the medicine be stopped, but hospice continued it anyway.  Her mother became unable to leave her room and died shortly after entering assisted living.

This story appeared in The Sentinel, a publication of the Senior Medicare Patrol Resource Center, an organization that provides resources to help Medicare beneficiaries to spot healthcare fraud.  The story has two red flags for potential fraud:

  • The hospice benefit appears to have been offered to a patient who had not been certified by a physician to be terminally ill. The hospice benefit, however, is intended for those who have been certified by a physician as having a life expectancy of only six months or less.
  • The hospice provider appears to have ordered redundant and unnecessary equipment and medication.

Indeed, new reports confirm that the Medicare hospice fraud and billing abuse are becoming a costly problem.  A recent investigation by the Department of Health and Human Services found that hospices billed Medicare for a higher level of care than patients need in about one-third of the cases, and reported that the extra cost to Medicare was more than $260 million per year.  While most hospice care is provided to beneficiaries in their homes, if symptoms become too difficult to manage at home they can be admitted to a hospital, nursing home, or hospice inpatient unit.  Medicare pays hospices a flat rate of $720 per day for such inpatient care, but no more than $187 a day for home care.

TSCL strongly supports measures to reduce Medicare fraud, as well as programs like the Senior Medicare Patrol that help patients and their families spot fraud.  To learn more about the Senior Medicare Patrol and where to report fraud, visit the Stop Medicare Fraud web page of the U.S. Department of Health and Human Services.


Sources: “Hospice Fraud Takes Advantage of People at the End of Life,” Nancy Aldrich and Jolie Crowder, The Sentinel, a publication of the SMP Resource Center, November 2014.