By Karen Fletcher
Hospice fraud continues to be one of the top three types of Medicare fraud reported to our California Senior Medicare Patrol each month. Not only is this fraud robbing Medicare and taxpayers of hundreds of millions of dollars each year, it is hurting Medicare beneficiaries. This can happen in a number of ways, as demonstrated in the cases discussed below, and includes losing access to much- needed medication and/or treatment, losing access to one’s primary physician, and in some cases, losing one’s health or even one’s life.
The four cases reviewed below were all reported to our California SMP and are actively being investigated.
Case #1: Beneficiary loses access to medication
In this case, an elderly Medicare beneficiary was unable to access her much needed medication due to a hold her pharmacy put on it. Not knowing why this happened and being unable to go without her prescription, this beneficiary called her daughter for help. Her daughter paid out of pocket for the meds, and called our SMP to see what happened. In researching the complaint, our SMP learned that the pharmacy put a hold on her mother’s prescription because she was enrolled in hospice.
Hospice is an important Medicare benefit for people who are terminally ill with 6 months or less to live. When in hospice, it changes one’s Medicare benefits to be focused only on palliative care, not curative care. This means that when on hospice, one’s Medicare will only cover meds that are palliative in nature. Any other meds will be denied. This is also true in terms of Medicare-covered services. When enrolled in hospice, Medicare will deny payment of any treatments or services intending to “cure” an illness. Therefore if a beneficiary has been fraudulently enrolled in hospice and is not terminally ill, they may start to notice Medicare denying their claims for treatments, services and doctor visits and may be forced to pay out of pocket.
In this case, the daughter had no idea her mother was enrolled in hospice, as she certainly wasn’t terminally ill. When SMP interviewed the mother, she claimed that a nurse came to her home and offered housekeeping services “covered by Medicare”. This “benefit” sounded great, so she signed up. Yet the mother had no understanding that she was actually signing up for Medicare’s hospice benefit.
Case #2: Medicare stops paying beneficiary’s medical bills
In another case, a beneficiary became concerned when Medicare stopped paying many of his medical bills, and he called our California SMP for help. In researching his case, our SMP found out he had been enrolled in hospice. Yet, when talking to him, this beneficiary had no idea this had happened. Unlike the elderly woman in case #1, no nurse or hospice representative called or came to his door. He believes his Medicare number was stolen and used to enroll him into hospice without his consent.
Cases #3 & #4: Fraudulent hospice enrollment causes beneficiaries’ health decline and death
Earlier this month, our SMP staff spoke with a son whose father died while fraudulently enrolled in hospice. He called SMP in his search to bring justice to the cause of his father’s untimely death and to help prevent other beneficiaries meeting the same fate.
The son, who was his elderly father’s caregiver, received a call from a nurse one day who said his father qualified for hospice because of his age. She said that Medicare’s hospice benefit could provide home care services and relieve some of the burdens of his caregiving responsibilities for his dad with in home nurse visits. She promised his dad would enjoy access to even more Medicare benefits through this program. The nurse also promised the program would coordinate with his dad’s primary care doctor and that he could still go to his medical check ups.
None of these promises came through. The son had his father enrolled in this hospice from May through December. During that time, his father’s health declined rapidly. The hospice company changed his medications and told him not to go to his doctor or emergency room.
As the son watched his father’s health decline, he wasn’t sure what to do. When his father was no longer eating or able to use the bathroom, the son took him to the emergency room. Weeks later, his father died. The son regrets ever agreeing to put his father in this hospice program. He truly thought he was helping his father and now, in hindsight, he sees the horrendous fraud that happened. And he sees how this fraud caused his father’s early death.
Another case (case #4) also recently came in that is just as severe as the previous case #3, yet has a shorter timeline. A daughter called our SMP to report this case of hospice enrollment fraud that resulted in her father’s untimely and unnecessary death. In this case, her father was hospitalized with pneumonia. While the family was visiting him on a Friday in December, a hospice company approached them to enroll him into their program. The family declined, stating he was “not there yet”.
The father was 85 years old and had been living independently before contracting pneumonia due to irritation from three months of wildfire smoke the previous summer and fall. The family was confident that once the pneumonia healed, he’d be back to living his healthy, independent life.
Before the family left from their visit, the father’s doctor came and told them that their father would stay in the hospital at least one more night. This would make sure they could give him his necessary medications to control the fluid in his lungs as the pneumonia healed.
Yet, after the family left, the hospice company did not heed the family’s wishes, enrolled their father into their program and changed his medications. They discharged him from the hospital and transferred him late Friday afternoon to a care home facility where the hospice company administered non-consented opioids and narcotics. The family strongly believes that their neglect of not giving him the necessary medications to manage the fluid in his lungs is what led up to his premature death. All this happened less than 48 hours after the hospice company had him leave the hospital.
Both cases #3 and 4 are egregious examples of hospice fraud that not only caused declined health but also premature death. While two such cases are already two too many, how many more people is this happening to? Through fraudulent hospice enrollments bringing about detrimental changes of medications, causing beneficiaries not to be able to see their doctors, etc. how many other people have experienced their health decline, and/or even worse had their life shortened because of fraudsters making money at the cost of their demise? All these cases strongly demonstrate that questionable hospice enrollment comes at an incredibly high price for beneficiaries.
Our California Senior Medicare Patrol (SMP) is working hard to stop such fraud. One way you can help is to educate yourself, your clients and your loved ones about hospice fraud, what to look for and how to avoid it. Here are some good tips to start with and share:
- Beware of hospice companies enrolling patients who do not have a terminal illness with 6 months or less to live. Medicare’s hospice benefit is only for those who are terminally ill.
- Don’t get tricked by hospice companies offering free services such as housekeeping and cooking. Medicare does not pay for this!
- Beware of calls or unannounced visits by hospice companies offering additional benefits such as help with cooking and cleaning.
If you or someone you know comes across such scams, please report any suspected hospice or other Medicare fraud to our California SMP at 1-855-613-7080.
Karen Joy Fletcher, MPH has over 20 years of experience in Medicare training, education and advocacy and has served as CHA’s Publications Consultant since 2004. She is the primary researcher, writer and editor of CHA’s website content, including CHA’s newsletter and blog. She also develops and revises key educational materials, spearheads CHA’s social media and chairs the Senior Medicare Patrol Media Team and SMP superheroes skit team.
In addition to her work in Medicare advocacy, Karen teaches Earthgym and Qigong at schools, conferences, festivals and retreat centers around the country and abroad, and co-leads Qigong & Wilderness retreat trips in China. She also enjoys ample nature and family time in the Cascadian forests and mountains.