Elderly patients spent over two weeks in uncontrolled pain or respiratory distress. Acute care was rare on weekends. And recruiters went door-to-door pitching fraudulent schemes, luring healthy patients to sign up for hospice in exchange for free housecleaning and medicine.
These details come in a report on hospice released Monday with a government watchdog agency contacting federal regulators to ramp up oversight of a booming industry that served 1.4 million Americans in 2021.
The report in the Office of Inspector General (OIG) in the Department of Health and Human Services covers over Ten years of research into inadequate care, inappropriate billing and outright fraud by hospices, which took in $16.7 billion in Medicare payments in 2021.
The Medicare hospice benefit aims to help patients live their final days in peace and luxury: It pays for agencies to transmit nurses, aides, social workers and chaplains to visit patients who're prone to die within 6 months and who agree to forgo curative strategy to their terminal illness. Most of the time, this care happens in which the patient already lives – their house, elderly care or assisted living facility.
A Kaiser Health News investigation this past year revealed that even though many of the nation’s 4,000-plus hospices earn high satisfaction rates on family surveys, hundreds fell lacking their obligations, abandoning families in the brink of death or skipping other services they'd pledged to provide.
The OIG report points to similar gaps in care and raises concerns that some hospices are milking the machine by skimping on services while consuming daily Medicare payments.
Regardless of how often their personnel visit, hospices collect exactly the same daily flat rate from Medicare for each patient receiving routine care: $193 for that first 60 days, then $151 thereafter, with geographic adjustments as well as extra payments in a patient's last week of life.
The report calls on the Centers for Medicare & Medicaid Services (CMS) to consider 15 actions to improve oversight, including tying payment to quality of care and publishing public inspection reports on its consumer-focused website, Hospice Compare, because it does for nursing homes.
In instructions to OIG in response to an earlier draft of its report, CMS Administrator Seema Verma objected to people two recommendations in addition to six others. She concurred with six other recommendations and wrote that CMS is “committed to ensuring that the Medicare hospice program provides quality care protected from fraud, waste, and abuse.”
The OIG findings include:
Basic care only: In 2021, 665 hospices provided only the most basic degree of care, called routine home care. This can be a warning sign, OIG argues, suggesting that patients may not be getting the care they require: Medicare requires hospices to offer three other types of care – general inpatient take care of acute conditions for example uncontrolled pain, continuous care inside a crisis and respite care to provide a caregiver temporary relief.
Inadequate acute care: Hospices didn't provide adequate nursing, physician or medical social services in 9 % of general inpatient care stays in 2012. Types of poor care included a 101-year-old man with dementia who had uncontrolled pain for 16 days, as well as an 89-year-old man who had uncontrolled respiratory distress and anxiety for 14 days.
Weekend visits rare: Hospices rarely provided services for fun on saturday to patients in assisted living in 2012. Hospices were also more prone to provide general inpatient care on weekdays than you are on weekends, according to an OIG analysis of 2011 data.
Missing services: In nearly another of Medicare claims filed for patients residing in nursing facilities, hospices provided fewer services than they promised in patients’ plans of care, according to a 2009 report. This really is notable, the OIG argues, because hospices set their own plan of care for each patient, and fell lacking the bars they established.
Few or no visits: Typically, hospices provided only 4.8 hours of visits each week, in exchange for $1,100 in weekly Medicare payments, for each patient receiving routine home care within an assisted living facility in 2012, OIG found. Most visits originated from aides. In addition, 210 of those patients did not get any hospice visits that year, despite Medicare paying $2.3 million for their hospice care.
Responding to these findings in her own letter, Verma said CMS has taken various actions, including: auditing certain hospices’ medical records before claims are paid, monitoring hospices that have many patients in nursing facilities and recouping money from hospices that inappropriately billed Medicare for general inpatient care stays.
While many of OIG’s findings date back over five years, report lead author Nancy Harrison, deputy regional inspector general from the OIG’s New York office, asserted the vulnerabilities within the system persist which CMS has failed to implement most of the recommendations OIG continues to be making for years. These vulnerabilities have emerged at a time once the industry is different rapidly, she said.
“Hospice is very diverse from it was once,” Harrison said. “When it started out, there were faith-based and nonprofits,” and many patients had cancer. By 2021, there were 4,374 hospices receiving Medicare money, about two-thirds which were for-profit.
Fraud has pervaded the industry, with some hospices ripping off taxpayers by enrolling patients who are not dying, paying kickbacks for patient referrals or undertaking various inappropriate billing schemes. From fiscal years 2021 to 2021, OIG investigators won back $143.9 million from 25 criminal actions and 66 civil actions against hospices.
Fraud has run wild in Mississippi, where hospices were paying recruiters to solicit business door-to-door from individuals who weren't dying. The recruiters offered free housecleaning, medicine and doctors’ appointments with patients who registered – being unsure of they were signing up for hospice and forgoing Medicare payment for curative care, based on OIG field agents. One recruiter, a convicted sex offender, was delivered to prison for 40 months in 2021 to take payments from five hospices, earning $200 to $600 for each hospice-inappropriate Medicare beneficiary he sent their way.
Also in Mississippi, hospice owner Regina Swims-King was sentenced in 2021 to almost six years in prison for an $8 million Medicare fraud scheme involving patients who didn't need hospice, services that patients never received and claims based on forged doctors’ signatures. She forfeited 12 real estate properties and 17 vehicles.
Charles Hackney, an assistant special agent in charge who oversees OIG investigators in Mississippi, said fraud there, that was perpetrated by small mom-and-pop operators, has subsided after many criminal convictions.
But nationally, fraud cases continue: Just last October, the federal government reached a $75 million settlement with Vitas Hospice Services – a large for-profit chain owned by Chemed Corp., which also owns the Roto-Rooter plumbing company – to deal with allegations of fraudulent billing.
Edo Banach, president from the National Hospice and Palliative Care Organization, a business group, was without a copy of the OIG report to review before publication. However in an argument, he explained “incidents of deliberate fraud and abuse within the hospice community, though rare and isolated, are indefensible.”
He said his group aims to utilize the Trump administration to “simplify and streamline the compliance process” in a manner that “encourages honest and law-abiding hospice providers” while avoiding fraud.
Banach suggested the OIG also examine a problem not mentioned in the report: “underutilization of hospice care, which keeps too many Americans from accessing quality end-of-life care once they require it.”