Attorney - Hospice Fraud - A characterize For Employees, Whistleblowers, Attorneys, Lawyers and Law FirmsGood evening. Today, I found out about Attorney - Hospice Fraud - A characterize For Employees, Whistleblowers, Attorneys, Lawyers and Law Firms. Which is very helpful for me therefore you. |
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Hospice fraud in South Carolina and the United States is an expanding question as the estimate of hospice patients has exploded over the past few years. From 2004 to 2008, the estimate of patients receiving hospice care in the United States grew approximately 40% to nearly 1.5 million, and of the 2.5 million population who died in 2008, nearly one million were hospice patients. The wonderful majority of population receiving hospice care receive federal benefits from the federal government through the Medicare or Medicaid programs. The health care providers who supply 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 isn't the actual final outcome that the true about Attorney. You read this article for info on anyone need to know is Attorney.AttorneyWhile most hospice health care organizations supply thorough and ethical medicine for their hospice patients, because hospice eligibility under Medicare and Medicaid involves clinical judgments which may effect in the payments of large sums of money from the federal government, there are broad opportunities for fraudulent practices and false billing claims by unscrupulous hospice care providers. As up-to-date federal hospice fraud obligation actions have demonstrated, the estimate of health care fellowships 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 keen a South Carolina hospice is Southern Care, Inc., a hospice business that in 2009 paid .7 million to resolve an Fca case. The defendant operated hospices in 14 other states, too, together 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 terminal illnesses, and that the business 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 agreement 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, together with hospice patients and their house 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 industrialized 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 field themselves to menagerial sanctions, together with lengthy exclusions from working in an assosication which receives federal funds, broad civil monetary penalties and fines, and criminal sanctions, together with incarceration. When a hospice employee discovers fraudulent guide keen Medicare or Medicaid billings or claims, the employee should not partake in such behavior, and it is imperative that the unlawful guide be reported to law obligation and/or regulatory authorities. Not only does reporting such fraudulent Medicare or Medicaid practices shield the hospice employee from exposure to the foregoing administrative, civil and criminal sanctions, but hospice fraud whistleblowers may benefit financially under the reward 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 behalf of the United States. Types of Hospice Care Services Hospice care is a type of health care service for patients who are terminally ill. Hospices also supply retain services for the families of terminally ill patients. This care includes physical care and counseling. Hospice care is ordinarily in case,granted by a group department or underground business stylish by Medicare and Medicaid. Hospice care is available for all age groups, together with children, adults, and the elderly who are in the final stages of life. The purpose of hospice is to supply care for the terminally ill patient and his or her house and not to cure the terminal illness. If a patient qualifies for hospice care, the patient can receive curative and retain services, together with nursing care, curative group services, physician services, counseling, homemaker services, and other types of services. The hospice patient will have a team of doctors, nurses, home health aides, group workers, counselors and trained volunteers to help the patient and his or her house members cope with the symptoms and consequences of the terminal illness. While many hospice patients and their families can receive hospice care in the comfort 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 estimate of days that a patient receives hospice care is often referenced as the "length of stay" or "length of service." The length of service is dependent on a estimate of different factors, together with but not wee to, the type and stage of the disease, the potential of and access to health care providers before the hospice referral, and the timing of the hospice referral. In 2008, the average length of stay for hospice patients was about 21 days, the average 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 in case,granted are nursing homes (22%), residential facilities (6%), hospice patient facilities (21%), and acute care hospitals (10%). Hospice patients are ordinarily 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 terminal 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 insurance (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% growth over ten years. There were about 3,700 fellowships 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 program to supply health insurance for the elderly and disabled. Payments from the Medicare program 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 department within the United States department of health and Human Services (Hhs) that administers the Medicare program 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 service operations, Medicaid and children's health, gawk & 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 business line. Each Ca is responsible for consistent implementation of Cms programs, policy and guidance across all ten regions for matters pertaining to their business line. In expanding to responsibility for a business line, each Ca also serves as the Agency's senior supervision official for two or three Regional Offices (Ros), representing the Cms Administrator in external matters and overseeing menagerial operations. Much of the daily supervision and execution of the Medicare program is managed through underground insurance fellowships that compact with the Government. These underground insurance companies, sometimes called "Medicare Carriers" or "Fiscal Intermediaries," are expensed with and responsible for accepting Medicare claims, determining coverage, and making payments from the Medicare Trust Fund. These carriers, together with Palmetto Government Benefits Administrators (hereinafter "Pgba"), a department of Blue Cross and Blue Shield of South Carolina, control pursuant to 42 U.S.C. §§ 1395h and 1395u and rely on the good faith and particular representations of health care providers when processing claims. Over the past forty years, the Medicare program has enabled the elderly and disabled to gather significant curative services from curative providers throughout the United States. significant to the success of the Medicare program is the basal idea that health care providers accurately and indeed submit claims and bills to the Medicare Trust Fund only for those curative treatments or services that are legitimate, inexpensive and medically necessary, in full compliancy with all laws, regulations, rules, and conditions of participation, and, further, that curative providers not take benefit of their elderly and disabled patients. The Medicaid program is available only to determined 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 program 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 program depends on health care providers to accurately and indeed submit claims and bills to program administrators only for those curative treatments or services that are legitimate, inexpensive and medically necessary, in full compliancy with all laws, regulations, rules, and conditions of participation, and, further, that curative 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 recognize 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 group 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. terminal illness is established when "the individual has a curative prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course." 42 C.F.R. § 418.3; 42 U.S.C. § 1395x(d)(d)(3). The patient's physician and the curative director of the hospice must guarantee 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 initial certification, Medicare provides for two ninety-day benefit periods followed by an unlimited estimate 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 normal course. 42 U.S.C. § 1395f(a)(7)(A). The written certification and re-certifications must be maintained in the patient's curative 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 in case,granted 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, together with plan of care, assessments, clinical notes, signed notice of election, patient responses to medication and therapy, physician certifications and re-certifications, outcome data, advance directives and physician orders. 42 C.F.R. § 418.104. The hospice must gather a written notice 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 curative medicine for the terminal 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 terminal illness and bereavement. 42 C.F.R. § 418.56. The Idg members must supply 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 supply coordination of care and to ensure continuous estimate of each patient's and family's needs and implementation of the interdisciplinary plan of care. The interdisciplinary group must include, but is not wee to, the following marvelous and competent professionals: (i) A physician of medicine or osteopathy (who is an employee or under compact with the hospice); (ii) A registered nurse; (iii) A group 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 inexpensive and significant for the palliation and supervision of the terminal 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 curative director, and the interdisciplinary group of the hospice program as set forth in §418.56. That plan of care must be established before hospice care is provided. The services in case,granted 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 group 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 inexpensive and significant for the palliation or supervision of terminal illness...." 42 C.F.R. § 418.50 (hospice care must be "reasonable and significant for the palliation and supervision of terminal 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, access 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 estimate 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 estimate of care required to meet beneficiary and house 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, normal patient care (5.74). The compound every year cap per patient in 2009 was ,014.50. This cap is carefully by adjusting the former hospice patient cap of ,500, set in 1984, by the buyer Price Index. See Cms Internet-Only hand-operated 100-04, lesson 11, section 80.2; 42 U.S.C. § 1395f(i); 42 C.F.R. § 418.309. The Medicare Claims Processing Manual, at lesson 11 - Processing Hospice Claims, in Section 80.2, entitled "Cap on wide 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 charge the patient for these co-insurance payments. However, the co-insurance payments for drugs are wee to the lesser of or 5% of the cost of the drugs to the hospice, and the co-insurance payments for respite care are ordinarily 5% of the cost made by Medicare for such services. 42 C.F.R. § 418.400. The Medicare and Medicaid programs need institutional health care providers, together 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 guarantee that they will comply with Medicare and Medicaid laws, regulations, and program instructions, and additional guarantee that they understand that cost of a claim by Medicare and Medicaid is conditioned upon the claim and basal transaction complying with such program 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 program instructions that apply to this provider. The Medicare laws, regulations, and program instructions are available through the Medicare contractor. I understand that cost of a claim by Medicare is conditioned upon the claim and the basal transaction complying with such laws, regulations, and program instructions (including, but not wee to, the Federal Aks and Stark laws), and on the provider's compliancy with all applicable conditions of participation in Medicare." Hospices are ordinarily required to bill Medicare on a monthly basis. See the Medicare Claims Processing Manual, at lesson 11 - Processing Hospice Claims, in Section 90 - Frequency of Billing. Hospices ordinarily 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 consist of representations and certifications which state in pertinent part that: (1) misrepresentations or falsifications of significant facts may serve as the basis for civil monetary penalties and criminal convictions; (2) submission of the claim constitutes certification that the billing facts is true, spoton and complete; (3) the submitter did not knowingly or recklessly disregard or misrepresent or conceal material facts; (4) all required physician 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 field to prosecution under applicable Federal or State Laws. Hospices must also file with Cms an every year cost and data article of Medicare payments received. 42 U.S.C. § 1395f(i)(3); 42 U.S.C. § 1395x(d)(d)(4). The every year hospice cost and data reports, Form Cms 1984-99, consist of representations and certifications which state in pertinent part that: (1) misrepresentations or falsifications of facts contained in the cost article may be punishable by criminal, civil and menagerial actions, together with fines and/or imprisonment; (2) if any services identified in the article were the stock of a direct or indirect kickback or were otherwise illegal, then criminal, civil and menagerial actions may result, together with fines and/or imprisonment; (3) the article is a true, spoton and complete statement ready from the books and records of the provider in accordance with applicable instructions, except as noted; and, (4) the signing officer is customary with the laws and regulations about the provision of health care services and that the services identified in this cost article were in case,granted in compliancy with such laws and regulations. Hospice Anti-Fraud obligation Statutes There are a estimate of federal criminal, civil and menagerial obligation provisions set forth in the Medicare statutes which are aimed at preventing fraudulent conduct, together with hospice fraud, and which help vocalize program integrity and compliance. Some of the more prominent obligation provisions of the Medicare statutes consist of 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 obligation provisions which are used to combat Medicare and Medicaid fraud, together with hospice fraud, consist of 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 association 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 reward 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 behalf 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 article 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 article or statement material to an obligation to pay or send money or asset to the Government, or knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay or send money or asset to the Government.... There is no requirement to prove specific intent to defraud. Rather, it is only significant 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 employee (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 estimate of back pay, interest on the back pay, and payment for any special damages sustained as a effect of the discrimination or retaliation, together with litigation costs and inexpensive 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 department where the frauds occurred, the relator's residence, and the defendant residence, will resolve which department 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 resolve either or not to intervene. While this time, federal government investigators located in South Carolina will explore 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 normal (Oig) has issued special 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 customary with these hospice fraud practices. Tips on recognizing hospice frauds in South Carolina and the U.S. Are: • A hospice gift free goods or goods at below shop value to induce a nursing home to refer patients to the hospice.
Recent Hospice Fraud obligation Cases The Doj and U.S. Attorney's Offices have been active in enforcing hospice fraud cases. In 2009, Kaiser Foundation Hospitals located an Fca lawsuit by paying .8 million to the federal government. The defendant allegedly failed to gather written certifications of terminal illness for a estimate of its patients. In 2006, Odyssey Healthcare, a national hospice provider, paid .9 million to resolve a qui tam suit for false claims under the Fca. The hospice fraud allegations were ordinarily 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 agreement 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., located claims an Fca claim for 0,000. The hospice fraud allegations were ordinarily 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 located 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, together with violation of the Aks for receiving illegal kickbacks from a hospice for recommending the hospice to the staff of his nursing home, located an Fca suit for million. Conclusion Hospice fraud is a growing question in South Carolina and throughout the United States. South Carolina hospice patients, hospice employees, and their Sc lawyers and attorneys, should be customary 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 compliancy with Medicare/Medicaid hospice billing requirements to avoid hospice fraud allegations and Fca litigation. © 2010 Joseph P. Griffith, Jr. I hope you obtain new knowledge about Attorney. Where you possibly can put to utilization in your everyday life. And just remember, your reaction is passed about Attorney. Read more.. Hospice Fraud - A characterize For Employees, Whistleblowers, Attorneys, Lawyers and Law Firms. |
Hospice Fraud - A characterize For Employees, Whistleblowers, Attorneys, Lawyers and Law Firms
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