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"Nursing"Thanks to three whistleblowers, St. Joseph Hospice and its majority owner are
forking over $5,867.518 to the federal and state governments to settle allegations that the hospice’s
thirteen facilities overbilled Medicare and Medicaid. According to the
Department of Justice and the whistleblowers, St. Joseph’s hospices
in Mississippi, Louisiana, Texas and Alabama submitted bills for extremely
expensive “continuous home care hospice services” for patients
who did not need that much care.

The Government is paying more than $1 million to the three whistleblowers,
all former St. Joseph Hospice employees, who filed suit under the False
Claims Act (FCA) to report the overbilling and try to stop it. Congress
passed the FCA to encourage whistleblowers to enlist in the Government’s
fight against fraud of all types, including, as this case illustrates,
hospice care fraud.

What are “continuous home care hospice services”?

While we tend to think of “hospice care” as a single type of
care, Medicare divides the care into four categories. One type, “continuous
home care,” or “CHC”, is supposed to be exceptionally
rare, given “during periods of crisis as necessary to maintain an
individual at home.” 42 C.F.R. § 418.204(a). Medicare defines
a “crisis” as “a period in which the individual requires
continuous care to achieve palliation and management of acute medical
symptoms.”
Id. Although some of the care can come from a hospice aide (home health aide)
or homemaker services, the care “must be predominantly nursing care.”Id.

In layman’s terms, when Medicare plunks down big dollars for continuous
care, it is presuming that the care is temporary because a patient is
in such medical crisis that he needs full nursing care. The care only
applies to hospice care that is given where the patient lives, whether
it be at home, in an assisted living facility, a long-term care facility
or at a hospice facility (unless the patient is an inpatient there). The
idea behind CHC is that the patient needs “nursing facility”-level
care on a temporary basis because he is not getting it anywhere else.
For that reason, a hospice cannot bill for continuous care when a patient
already is receiving “nursing facility” care somewhere. For
example, a hospice cannot bill continuous hospice care for a patient who
has been admitted to the hospital for acute care, is receiving inpatient
hospice treatment, or is being cared for in a skilled nursing facility.

Why does the Government limit continuous care?

Continuous hospice care is very expensive. Medicare pays a hospice nearly
6 times as much for continuous care as for routine home hospice care.
The idea behind the big-bucks payments is that the patient needs very
intensive care on a temporary basis, to resolve a crisis. Medicare has
not agreed – could not afford to agree – to reimburse all
hospice care at the higher rate. If hospices bill that level of care for
patients who do not need it, Medicare quickly will become unable to afford
that level of healthcare for anyone – even those patients who desperately need it.

What was St. Joseph accused of doing?

DOJ said that St. Joseph was billing continuous hospice care for patients
who were not in crisis, and therefore were not eligible for CHC. St. Joseph
was an “outlier,” DOJ said, meaning that compared to other
hospice facilities, St. Joseph claimed that a lot more of its patients
were in crisis and therefore eligible for CHC. Noting that continuous
care should be “rarely used,” DOJ said that not all of St.
Joseph Hospice’s patients actually needed CHC-level care.

The whistleblowers filed suit in 2012 in the Southern District of Mississippi.