Today is going to be a complicated diary. It won't come down to a slate of simple slogans or a 30 second sound bite. It can't. It's about Medicare fraud, Medicare hospice program fraud to be precise. I tried to block it out so you can skim the high low points, but to really appreciate this one, you'll need to go get a cup of whatever and have a sit to fully process this. Above the fleur de kos is the diary and below the fleur de kos is some extra info helpful to understanding Medicare, hospice, health care fraud and this current qui tam law suit.
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In another example of just how greed based the United States health care system is, the Justice Department joined (pdf) a whistle blower suit (pdf) (aka qui tam law suit) against AseraCare (Golden Gate National Senior Care LLC) for systemically defrauding the Medicare Hospice program.
Systemically is the key word. It was a corporate wide, all hands on deck pursuit of profits that led more than one employee to ignore Medicare rules and regulations either through ignorance or intention. Compliance was a concept that only got lip service. Training employees to comply with complicated Medicare rules were a sham. Some training (intentionally?) misrepresented Medicare rules. Departments were kept separated to prevent dot connections. Operational Directors and Regional Managers pushed for admissions in the most intrusive and calculating ways imaginable. Patients were routinely fraudulently certified as terminal or non-terminal based solely upon reimbursement. Hospice physician medical directors were out of the care loop. Employees were encouraged to find imminent death patients anywhere to improve their Aggregate Cap picture. Any employee who objected to the MO was "not a team player". The result is 70+ pages of court filings detailing some egregious patient abuse.
The seventy plus pages are sickening. How many patients died who had conditions amenable to treatment is unknown. The number of imminent death patients subjected to intrusive treatment when they didn't want it is possibly calculable.
How this works
The game is to use a revolving door to home health, SNF (Skilled Nursing Facility) and hospice companies to maximize the bilking of Medicare dollars.
A Medicare patient initially has a max of 150 consecutive days in the hospital.
Then they either would be discharged to their homes with Part B home health services for at least 60 days to reset the benefit period to zero or is sent onto hospice where they need to be periodically recertified as terminal.
If the patient is sent home, they can still receive intraventive care.
If the patient is sent to hospice, they can only receive palliative (comfort) care.
A lot of times, a patient will stop the intraventive care and go to hospice because of the discomfort of treatment only to change their mind some weeks or months later after they feel better which justifies the "ooops, I'm sorry" discharges.
A Medicare patient who has a reset benefit period under Medicare Part A, but has expended their lifetime reserve days now has a maximum stay of 90 consecutive days in the hospital/SNF or Part A home health.
The game continues until someone at the MAC (Medicare Administrative Contractor, which used to be called a fiscal intermediary - the private companies that actually run the Medicare programs) decided that the statistics are well under the tails of the bell curve.
The Mac takes too long to investigate and sics a RAC auditor on it
The MAC brings in the DOJ
Seven years or so later.....
geesus!
Really!
Oh, yeah, this is waaaaay too complicated for the average patient and their families to perceive.
How to manipulate the patient and their family
Any patient or family member who balks at any of these moves is coaxed and manipulated by a well trained staff member who is directed by managers to say whatever will work best for the corporate bottom line:
1. Don't you want to live?
2. Don't you just want some peace?
3. Medicare will pay for this.
4. Medicare won't pay for you to continue....
5. Don't you want to go home?
6. Wouldn't it be better if you could have someone available 24/7?
7. I think your situation has changed and....(insert any of 1-6 here)
8. You can be transferred to hospice and maybe if you get stronger, you can come back for more treatment (this one is risky).
Health care employees easily buy into saying these things. Most inherently want to defeat death every patient, every day. It's the evil disease, administrator or insurance company that gets in the way. The hospice, SNF or home health employee is not let in on the overall strategy, they get a case by case directive. They follow orders, keep their head down and remain on the team. The game can't happen without them, so, the company finds ways to keep the game going without triggering their employees' conscience. They find ways to give their employees plausible deniability by using (among other methods) HIPAA to limit record access. The legal "knew or should have known" standard can be challenged, by limiting employee access to the cold, hard facts.
Private insurers get scammed too, but they don't have to report when they are duped and they deal with the scam by simply raising premiums. The perversity is that the more medical care dollars a private insurer spends, the more dollars they have to spread around on administration under MLR restrictions.
This isn't the first Medicare Hospice qui tam suit under the False Claims Act.
It won't be the last either.
This is what for profit health care is all about. Dollars over lives every time. A corporate culture that preaches integrity, but delivers misrepresentation.
The amount of fraud is likely in the millions. It could be incalculable, because the charts may not tell the whole story.
To understand this scheme you have to understand what Aggregate Cap (pdf) really means. It's the reimbursement limit Medicare places on a hospice center to avoid over utilization. In 2011 it is $24,527.69 per patient. That means the hospice adds $24.5k per admission to their "Aggregate Cap" calculations. The hospice is constantly comparing the actual costs they bill to Medicare to their Aggregate Cap limitation. If the hospice exceeds the Aggregate Cap, they must refund the difference to Medicare. This system is meant to discourage admitting patients who are too healthy and are likely to benefit from intraventive care like chemo, surgery, radiation or physical therapy for their terminal diagnosis. To offset the limitation you would constantly call oncologist offices for referrals to patients within 30 days of dying that would cost the hospice about $2,500 to care for and would give them an additional $22k unspent funds under their aggregate cap. Yep, that's cold, hard calculations that someone like Mitt Romney or Rick Santorum can admire.
To understand this scheme you have to see some of the hospice professional organization's advice on the subject of the Aggregate Cap.
(Emphasis from the source)
Eligibility is now objectively defined by clinical criteria, and eligible patients are now entitled to remain enrolled in hospice services until they die, regardless of how long it takes.
snip,
___________________________________________________________________________
A hospice that “hits their Cap” is required to repay Medicare for covered services already provided to eligible Medicare beneficiaries. Hospices don’t have this money; they spent it taking care of eligible dying patients.
___________________________________________________________________________
snip, again,
Consequences of the Medicare Hospice Cap
To attempt to avoid “hitting its cap”, a hospice has three choices:
1. admit only cancer patients, who have more predicable and shorter prognoses, or
2. discharge patients who “live too long” whether they remain medically eligible for hospice or not, or
3. care for patients who elect the hospice benefit for however long they remain eligible.
The first two alternatives deny patients the access to hospice care that Congress specifically intended, and no hospice wants to discharge patients who are eligible to receive care. The Cap makes the third alternative a prescription for bankruptcy for many hospice providers.
The final paragraph gives the "professional organization" plausible deniability. The MBA SNF/hospice/home health executive is going to discount that last paragraph and zero in on the money strategy.
How "the suits" make it happen
There will be no proof that the executives of this company had a formalized strategy session where all this was laid out as a cohesive plan. It was done bit by bit. One meeting at a time. One conference call at a time. Little by little the management team zeroed in on one problem at a time and created a "metric" for each item until the result became this lawsuit.
The "metrics" management likely created are:
1. New admissions
2. Aggregate Cap
3. Patients that billings exceed $24,527.69
4. Patient with billings at 90-99% of $24,527.69
5. Discharges to other care settings
6. Discharges due to death
7. "Sales" numbers for every conceivable revenue source
8. "Cost" numbers for every conceivable non-billable item or service
9. Billable services per patient ratio
10. Non-billable services per patient ratio
11. More the same
Some metrics make the higher number desirable, others, it's the lower. From the metrics it's easy to encourage the numbers management wants by using the 3 R's of managment (Recognize, Reward & Reinforce). Recognize the "good" side of every number and Recognize the employees who deliver the "good" side of every number. Reward "good" numbers with better reviews, higher pay, perks or awards. Reinforce getting "good" numbers by consistently keeping the goals in the employee's minds with frequent meetings, trainings, conference calls, flyers, email and whatever it takes to achieve the "good" number. Discourage "bad" numbers with the silence when a "bad" number is reported on a conference call. Say, "Did I hear that right (in disbelief) on a conference call. Use body language and verbal emphasis to "encourage" the "good" number. That's the Harvard Business School method. The recipe to success. Except, in this case, they forgot the lesson on "Don't get caught". Was it luck or did some one piss off the wrong person at the wrong time?
What They Do When "Caught"
The CEO will say they didn't know what was happening at the individual centers as all they get are management reports. The Regionals will say they weren't aware of what the branch managers Directors were doing. The Branch Directors will say they had no idea.... The billers for each entity are separated so they never were able to compare notes. The CFO will say they only got management reports. The duplicity will be sickening. AseraCare's response to this suit was and is predictable.
The False Claims Act qui tam suit
The examples cited in the 53 page initial complaint and the 29 page federal complaint are blatant examples of how corporate health care games the Medicare system. A lawyer might comment that the court date isn't set yet and the jury hasn't given their verdict, so we have to say "allegedly occurred". Ok, but if precedent set by other companies sued under the False Claims Act is any indicator, it's likely this case will be settled with a large payment going back to Medicare. The typical no acknowledgement of wrongdoing will be a stipulation made by AseraCare's parent company. Like Rick Scott's HCA hospital chain, the full extent of AceraCare's misdeeds will likely go untold.
Following the money in the filings shows AseraCare's systemic approach to maximizing all they could get from Medicare. Their parent company operated both Skilled Nursing Facilities (SNF's), home health agencies and Hospice centers making covering up the sham easier.
The Politics of Medicare
The main issue I've always have with Medicare is that due to politics, no program they come up with is simple. There's no simple formulas, no simple programs. All of it is complicated and requires concentration and attention to details to understand it. It's needlessly complicated. So complicated that it is too easily gamed by the minions of souless corporations that serve the god mammon. So complicated that it requires sophisticated software to detect the fraud. So complicated that qui tam lawsuits are filed seven years after the start of the fraud.
I'm happy that the Justice Department is going after our ill spent tax dollars, but damn, wouldn't it be less expensive to have a one cohesive system for everyone?
Background information helpful, but not necessary to the diary:
Here's a snippet from the initial court filing:
Since becoming a clinical manager in 2004, Ms. Richardson has become increasingly concerned by intense pressure from corporate management to maintain budgeted enrollment numbers and increase referrals and by implementation of corporate policies designed to avoid Medicare requirements and restrictions by evading regulations. Ms. Richardson has personally reviewed numerous patient documents and conducted in-person patient visits that demonstrate that patients who do not qualify for the Medicare Hospice Benefit have been fraudulently admitted and certified by Defendants and submitted for reimbursement from the government through Medicare. Ms. Richardson has been instructed by supervisors and corporate managers – and has witnessed the instruction of other nurses – to admit non-qualifying patients, to dump problem patients without regard to qualification, and to aggressively target imminent-death patients in order to deceptively and fraudulently shrink AseraCare’s average length of stay and average per-patient expenditure and thus to evade detection of Defendants’ fraudulent billing Medicare and to avoid liability for repayment of funds in excess of allowable Medicare reimbursements.
and,
Under the guise of "synergy," defendants have implemented a fraudulent scheme to manipulate the Medicare system and maximize their potential profits from each Medicare patient at the expense of the patient and the Medicare system. Defendants comprise a family of companies operating under the Golden Living/Golden Horizons umbrella and offering a range of Medicare-supported health care services to the elderly. Specifically, Defendants offer skilled nursing care, including therapy services through Aegis, home health care, and Hospice services through AseraCare. Defendants utilize their various subsidiary operations to recruit and fraudulently enroll elderly patients who are then fraudulently referred between organizations in whatever manner will result in the highest possible Medicare reimbursements, without regard to propriety, qualification, or the individual wellbeing of the patient.
Now, from the feds
The United States alleges that AseraCare, through its reckless business practices, admitted and retained individuals who were not eligible to receive Medicare hospice benefits, because it was financially lucrative - and did so even after AseraCare's auditor alerted AseraCare to troubling problems. AseraCare misspent millions of Medicare dollars intended for Medicare recipients who have a prognosis of six months or less to live and need hospice care.
Specifically, the United States alleges that AseraCare is liable under the false Claims Act, 31 U.S.C.3729 et seq., dut to AseraCare's conduct in submitting false and fraudulent records, statements, and claims for payment by the United States to the Medicare Program from at least January 2007.
and an interesting bit the feds snipped off AseraCare's email records,
40. For example, on October 31, 2008, a regional vice president emailed the executive directors and directors of clinical services of the numerous AseraCare providers, stating "[i]n order to make our admission goal for the month, we are down to the wire, and need today to be a huge admit day for every region." The regional vice president urged the executive directors and directors of clinical services to "[m]obilize your teams, get them into the game this morning[;] when we call on them they always respond with referrals and a push to convert those referral in admits ASAP".
41. On October 31, 2008, the director of operations for AseraCare hospice region 3 forwarded the same email from the regional vice president to the executive directors and directors of clinical services within region 3 urging them to find more patients to admit. "The highest admit day ever was in Region 1 with 16. We can get there too - today is the day for really focused action. Go around the barriers and make this happen now, your families need you," the director of operations wrote.
and,
65. Patient 2 was admitted to hospice by AseraCare on May 7, 2007 purportedly for end-stage heart disease. Although Patient 2 had heart disease, he did not meet the criteria for end-stage heart disease at any time during his hospice admission. End-state heart disease patients are typically unable to walk due to extreme shortness of breath. Patient 2's medical records documented that he was stable and able to walk on a regular basis including but not limited to notes that indicated that he was "wandering" in the nursing home.
(The notes indicated the patient successfully went to his granddaughter's graduation and berry picking with a friend. He also had a grand Christmas visit with his family and was ultimately discharged from hospice care so he could seek interventive care for his medical conditions. .....I can only imagine.)
Medicare Part A limitations:
Hospital stays
1-60 days have a deductible of $1,156
61-90 days add an additional $289 per day
91-150 days are lifetime reserve days and add an additional $578 per day
Using this complicated formula, the maximum number of days a patient can stay in a hospital, rehab facility or SNF is 150 days, but if a patient can be certified as terminal with a prognosis of being likely to die within 6 months; they can be transferred to hospice care. In hospice a patient then needs to be re certified as likely to die within 6 months every 60 days, but Medicare will continue to pay for their care until they pass away - within a complicated set of restrictions.
Medicare is needlessly complicated. Don't believe me? Take a look on page 34 of this pdf for figuring out the patient's deductible for a 95 day hospital stay where they received 1 blood transfusion. Go ahead, I'll wait.
Back already?
If you got $9,826 you're correct (but this example excludes what Medicare supplemental/Medigap insurances will pay of this deductible - 100% of it isn't guaranteed). That $9,826 just covers the hospitalization. It won't cover any diagnostic tests, imaging, lab tests or a lot of different drugs. It won't cover your doctor's visits to you (but will possibly cover the facility employed physician). It won't include any physician's operative services, medical procedures, anesthesia and so on. Most of what isn't covered under Part A is billed under Medicare Parts B or D with equally complicated formulas to determine what portions of the charges are payable by the patient.
Hospice
The Medicare Hospice Program has changed a lot over the years. In 1989 the hospice total benefits paid was $205 million. That number grew to $12.1 BILLION in 2009. That's 5,902 percent increase or 59 times the 1989 figure whichever boggles your mind less. Most of that growth in gross dollars occurred from 1998 to 2009 ($2.2 billion to $12.1 billion). The games really cranked up starting in 1998 which is about the same time hospital boards started to favor MBA's over MHSA's (Masters of Health Services Administration) for health care executive positions.
People get 4 year degrees in this stuff.
People get advanced degrees in this stuff.
Full disclosure, I have both an advanced degree and am a certified coder for this stuff.
Cases like this make me sick, angry, dispirited, and more determined to do what I can to make our system more functional.
You gotta wonder just when the Tea Party, Libertarians, the GOP, the independents and the DINOS are going to catch up with Progressives and Liberals in calling for at the very least a simpler universal health care system or Single Payer?