Understanding Medicare Hospice Benefits Can Help Eliminate Fraud

by Barbara Parrott McGinity, LMSW, Program Director, Texas Senior Medicare Patrol

What is Hospice care?
Hospice care is designed for patients with six months or less to live if their disease runs its natural course. It is typically given in the comfort of the patient’s home or in a Medicare approved hospice facility.
A patient receives hospice care in two 90-day “benefit periods” followed by an unlimited number of 60-day benefit periods if the patient is still eligible for hospice care. A patient can continue to receive hospice care after the six month period as long as they are recertified by a hospice medical director or hospice doctor. The certification must be provided before every benefit period.

Who is eligible?
To qualify for the Medicare Hospice benefit, a patient must meet the following criteria:
1) is eligible for Medicare Part A;
2) doctor and medical hospice director certify the patient is terminally ill (six months or less to live if the disease runs its natural course);
3) patient signs a statement choosing hospice care over any other Medicare-covered benefits to treat the illness; and
4) must receive care from a Medicare-approved hospice .

What happens when a patient chooses hospice care?
When a patient selects to receive hospice care, they are waiving their rights to Medicare payment for:
1) hospice care provided by a different program during the same time frame;
2 ) services related to the treatment of the patient’s terminal illness, and
3) services considered equivalent to their hospice care, except the services provided by the hospice program or the attending physician. Important: Medicare will still pay for covered benefits for health problems not related to a terminal illness, like care for an injury.

How does a patient stop hospice care?
If a patient is no longer terminally ill or their illness goes into remission, they no longer qualify for hospice care. In addition, a patient can elect to stop hospice care at any time and resume the Medicare coverage they had before hospice care. A patient can also elect to return to hospice care for any benefit periods they are eligible to receive.

What is Hospice Fraud?
All areas of hospice care may be subject to fraud of some kind. When dealing with hospice care it is important to remember that the frequency and types of services are to be determined by the NEEDS of the patient, not the staffing limitations of the agency.

Examples of hospice fraud:

  • Reducing the frequency of home health aide visits.
  • Using less qualified staff in roles which requiring the skills of a Registered Nurse.
  • Reducing the frequency of case manager visits to the patient. A telephone call from a Registered Nurse is not a substitute for an on-site assessment of the patient’s condition.
  • Skimping on pain medication.
  • Providing equipment that the patient does not need.
  • Refusing to provide oxygen to patients who are short of breath or who need oxygen for other reasons.
  • During a crisis, refusing to provide continuous, around the clock care in the patient’s own home.
  • Telling the family and patient that the hospice doesn’t have enough staff to provide in home care and they need to move to a facility.
  • Moving a patient to a facility allows them to bill Medicare at a higher rate for continuous nursing care plus fees for room and board.
  • Asking the family to pay out of their own pocket for services covered by Medicare and Medicaid. The family may not see what is billed or the bill may arrive after the patient is deceased and they do not read the statements or understand what has been double-billed.
  • Hospices receives a kickback for referrals from a hospital or nursing home.

What to Look For:

  • If your loved one is NOT getting the services needed.
  • If the hospice is trying to talk you into transferring your loved one to their facility.
  • If your loved one is NOT being kept comfortable
  • If there is inadequate staff and you are doing most of the care giving.
  • Demand that the hospice provide the services needed to meet the needs of the family and patient. The law requires the hospice to meet the needs of the patient and the family!

What to Do:

  • Read all the printed literature, documents and contracts you received from the hospice.
  • Know what services are required to be provided. This will help you protect your loved one from exploitation.
    Report potential fraud. Contact the Texas Senior Medicare Patrol at 1-888-341-6187.
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