Recent hospice settlements highlight where things can go wrong

Two recent settlements highlight important Medicare hospice program requirements and the need to remain vigilant about compliance with Medicare program rules.

The first settlement involved Charles Cole Memorial Hospital’s (CCMH) failure to perform required face-to-face (FTF) encounters with Medicare hospice patients prior to the third benefit period recertification and every subsequent benefit period recertification. CCMH self-disclosed the compliance issue to the Department of Health and Human Services Office of Inspector General (OIG) and agreed to pay over $373,000 to resolve its liability related to this compliance issue (along with an unrelated compliance issue the hospital also self-disclosed). 

In the second settlement, which occurred in November 2017 but was just announced by the Department of Justice in May 2018, Health and Palliative Services of the Treasure Coast, Inc., Hospice of Martin and St. Lucie, Inc. and Hospice of the Treasure Coast, Inc. agreed to pay $2.5 million to settle false claims allegations brought on by two whistleblowers who were medical doctors formerly employed by these hospices. The settlement related to allegations that the hospices billed Medicare for patients who were not terminally ill and, thus, did not qualify for the hospice benefit. In addition to the $2.5 million settlement, the hospices entered into a five-year corporate integrity agreement with the OIG. The whistleblowers received over $476,000 as their share of the settlement.

The hospice FTF encounter

Medicare rules require that a hospice-employed or hospice-contracted physician, or a hospice-employed nurse practitioner, provides and documents the FTF encounter with a Medicare hospice patient in order to complete the recertification for the patient’s third benefit period and every subsequent recertification thereafter. The FTF encounter must occur within 30 calendar days before the start of the third benefit period and for each recertification thereafter. Failure to conduct a timely FTF encounter means the beneficiary is no longer certified as terminally ill and the patient is no longer qualified for the Medicare hospice benefit. (See Medicare Benefit Policy Manual, chapter 90, section 20.1.)

Hospice eligibility

To be eligible for the Medicare hospice benefit, an individual must be entitled to Medicare Part A and be certified as terminally ill. Under the Medicare hospice rules, an individual is considered to be terminally ill if the medical prognosis is that the individual’s life expectancy is six months or less if the illness runs its normal course. No one other than a medical doctor or doctor of osteopathy can certify or re-certify a terminal illness.