Home Healthcare, Nursing Home and Hospice

Roughly thirty percent of Medicare dollars are spent on end-of-life care. This includes billings for home healthcare, nursing home care, and hospice care. Increasingly, enforcement resources are being trained on fraud in these areas.

The most common FCA violations by nursing home operators, hospice facilities, and home health care agencies include knowingly:

  • Billing for care that was not medically necessary
  • Billing for care that was not actually provided, or not provided as claimed
  • Offering, paying or receiving remuneration to influence the referral of patients (“kickbacks”)
  • Using billing codes that reflect a more severe condition than actually existed or more expensive care than was actually provided (“upcoding”)
  • Billing for services performed by an improperly supervised or unqualified employee
  • Billing for “worthless” services
  • Enrolling patients for hospice care who are not terminally ill (i.e., who have a medical prognosis of a life expectancy of more than six months)
  • Engaging in “beneficiary sharing”
  • Violating face-to-face documentation requirements
  • Submitting claims for services for dates after a patient’s date of death

Case Examples

Several major False Claims Act cases have been brought against nursing home operators, hospice facilities, and home health care agencies. By way of example:

In 2013, the Ensign Group, which operates nursing homes across the western U.S., agreed to pay $48 million to settle whistleblower claims that the company violated the False Claims Act by knowingly submitting claims to Medicare for medically unnecessary rehabilitation therapy services. The whistleblowers in this case were two former therapists for the Ensign Group. Read more

In 2011, Maxim Healthcare Services, Inc., one of the nation’s largest providers of home healthcare services, agreed to pay more than $120 million to settle whistleblower claims that it violated the False Claims Act by submitting bills to government health programs for services not provided or otherwise not reimbursable. The whistleblower in this case, who received $15.4 million as his share of the settlement, was a Medicare patient who alleged that Maxim fraudulently billed Medicare so many services under his name, none of which he ever received, that they exceeded a monthly Medicaid cap, ultimately resulting in his being denied needed health care services.

In 2009, one of the nation’s largest hospice providers, SouthernCare, agreed to pay $24.7 million to settle whistleblower claims that it violated the False Claims Act by enrolling, and submitting claims to Medicare, for patients who were not terminally ill or eligible for end-of-life care. The whistleblowers in this case were two former SouthernCare employees.

Also in 2009, Regency Nursing and Rehabilitations Centers, Inc. agreed to pay $4 million to settle claims that it violated the False Claims Act by submitting claims to Medicare and Medicaid for reimbursement for rehabilitation and skilled nursing services that were not medically necessary, were not supported by adequate documentation, or for which nursing residents were not eligible.

If you have knowledge and solid evidence of fraud or false claims by a nursing home operator, hospice facility, home health care agency or another health care provider, please contact our Chicago whistleblower attorneys.
Consultations are free and confidential.