Hospice providers deliver a wonderful, unique service that can make a big difference in the end-of-life experience, not only for patients but also for their caregivers and families.
Sadly, scammers are taking advantage of the federal government program that funds hospice care — by providing unneeded care or not enough care — hurting victims at a vulnerable time in their lives and costing taxpayers billions of dollars.
Medicare has provided a hospice benefit, which is paid through Medicare Part A, since 1983. Once an eligible patient elects hospice, Medicare, through the Centers for Medicare & Medicaid Services (CMS), pays the hospice provider for all care related to the terminal illness and related conditions. A Medicare patient is eligible for the hospice benefit if they have a medical prognosis that their life expectancy is six months or less if the illness runs its normal course. As the community’s need for hospice care increases, the scale of the Medicare-funded program also increases, making it a large target for fraud.
Learn how to spot and avoid hospice Medicare fraud so that you can make sure you or your loved one receives quality end-of-life care when it’s appropriate.
What to Expect from Hospice Care
End of life can be a particularly difficult and fraught time to navigate, even more so because hospice care is often misunderstood. To understand how to avoid hospice fraud, it’s important to first understand what hospice is and who it’s for.
Hospice care is provided by an interdisciplinary team that works together focusing on the patient’s physical, emotional, and spiritual needs during the last six months of life. Hospice also provides emotional, spiritual, and grief support to patients’ loved ones.
Among its major responsibilities, the hospice team provides a variety of specialized services:
- Design a care plan, crafted in consultation with the patient/caregivers and signed by the hospice physician with nurse visits as frequently as the patient’s condition requires, but at least every 14 days
- Provide durable medical equipment such as hospital beds and wheelchairs, supplies such as oxygen, bandages, and pads, and drugs needed
- Manage the patient’s pain and symptoms
- Offer emotional support
- Coach caregivers on how to care for the patient
- Deliver special services like speech and physical therapy when needed
- Make short-term inpatient care available when pain or symptoms become too difficult to manage at home or when caregivers need respite time
- Provide grief support, also known as bereavement support
These services, as mentioned, are paid for by Medicare. Like other Medicare benefits, this has made hospice a target for scammers and fraudsters.
Recognizing Hospice Medicare Fraud
Unfortunately, just as fraud exists in all segments of our healthcare system, there is fraud that targets the Medicare hospice benefit and harms patients.
Hospice fraud, in short, is people billing Medicare for unneeded or undelivered hospice-related services.
There are several different ways that individuals or groups with bad intent can commit fraud:
- People who are inappropriate and ineligible for the hospice benefit may be enrolled. By inappropriate, we mean individuals who are clearly likely to live longer than six months from the time of their enrollment. People can and do live longer than six months with hospice care, and that can be paid for if the patient remains eligible. However, scammers actively solicit people to enroll in the hospice benefit knowing they do not qualify, and bill Medicare for services that they may or may not deliver. These bad actors may also keep people enrolled in hospice when there is no longer a medical justification.
- Older Americans may be enrolled in hospice without their permission or knowledge, after scammers have obtained their Medicare number and other personal information.
- Gifts and services such as housekeeping or delivery services may be aggressively marketed along with other enticements as incentives to enroll in hospice. This is illegal and unethical.
- People in assisted living facilities or nursing homes with a life expectancy greater than six months may be targeted. People in assisted living facilities or nursing homes may be vulnerable if they don’t have advocates working on their behalf and may be persuaded to enroll in hospice when it is not yet appropriate.
- Services that are part of the hospice benefit may not be provided. For instance, they may provide less care on weekends, disregard the patient’s care plan, not respond to calls, or not send nurses or physicians when needed.
- Finally, bad actors may bill Medicare for more complicated services than provided or for services not provided, even when the patient is appropriately enrolled in hospice.
Protecting Yourself and Your Loved Ones from Hospice Scams
One of the most important things you can do is not share your personal information, including your Medicare number, social security number, and birthdate, with anyone you do not know. This includes through unknown individuals calling, texting, approaching you on social media, appearing at your door, or soliciting you in a public setting like a grocery store.
There are other ways you can protect yourself and those getting care as well:
- Don’t be afraid to ‘interview’ or ask questions of a new healthcare or hospice provider to help ensure you are finding the right care for you, and care that is provided by a legitimate provider. CaringInfo’s Choosing and Finding the Right Hospice Care for You is a valuable resource in this process.
- Consult with your doctor about your choice of hospice care and ask if they recommend any providers that service wherever you call home. While you don’t need a physician’s referral to ask about hospice care, your physician can be a good partner in finding a high-quality care provider. Your physician and the hospice physician will also help determine if you are eligible for hospice; different diseases have different markers to estimate your prognosis. Eligibility is not an exact science, but appropriate forecasts can be made. Further, there is nothing wrong with exploring these options before you are eligible for hospice care. Having awareness of your options early can help you make clear-headed decisions later.
- Do not accept gifts or enticements as solicitations to enroll in hospice, and report (see below) any providers offering gifts or enticements.
- For those enrolled in traditional Medicare (as opposed to a Medicare Advantage or MA plan), review your Medicare Summary Notice (MSN) on a regular basis. Medicare’s Medicare.gov website allows beneficiaries in original Medicare to log into or create a secure Medicare account to view their most recent MSNs, track claims made on their behalf, and check payment status. Creating a free, secure account with Medicare allows you to review all bills processed within the past 36 months.
- For those enrolled in Medicare Advantage, review your Explanation of Benefits (EOB) on a regular basis. Most Medicare Advantage Plans also have patient portals and allow you to set up an account where you can review your records and EOB’s.
- Educate yourself using Medicare’s Senior Medicare Patrol (SMP) program. Its goal is to empower and assist Medicare beneficiaries, their families, and caregivers in preventing, detecting, and reporting healthcare fraud, errors, and abuse. SMP provides links to your state’s programs on the main page which contain phone numbers, websites, and social media. Resources are available in many languages. The Senior Medicare Patrol site also contains a one-page summary about Hospice Care and Medicare Fraud as well as information on how to read your MSN’s and EOB’s.
- Stay up to date on the variety of Medicare scams. Senior Medicaid Patrol’s website also provides information on the types of scams, including ambulances and durable medical equipment, in addition to the section on hospice fraud.
- Share this information with your community. Help them avoid fraud.
What to Do if You’re Not Getting Adequate Services or Suspect Fraud
If you believe you are dealing with fraud or suspicious activity, the Senior Medicare Patrol provides the resources you need to make a report.
If you are experiencing an issue with the quality of care you or your loved one is receiving but do not believe it to be fraud, the Beneficiary and Family Centered Care-Quality Improvement Organizations helps Medicare beneficiaries with provider concerns.
Finally, each state also offers a hotline for reporting concerns and complaints about hospice care. Find your state-specific reporting hotline through this CMS resource.
Medicare provides many valuable programs to the American people. It is both sad and infuriating that people scam the system that helps and supports us all. We encourage you to use hospice services when appropriate—they can make an enormous difference in the end-of-life experience for all concerned—and to be vigilant in protecting Medicare and our loved ones from bad actors.
Learn more about the valuable services hospice care can provide us all.
