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Aug 13, 2021 by |

Orange County Whistleblower Attorney: False Hospice Certifications


False Hospice Certifications And False Claims

Blowing The Whistle On False Certifications

Medicare Reimbursement For Ineligible Patients

Hospitals, nursing homes, clinics, labs, drug and medical device manufacturers and physicians groups are each healthcare businesses that may defraud the government particularly for Medicare or Medicaid reimbursement for their services or products. The fraud may include illegal kickbacks, false billing, upcoding, sales of unapproved drugs, illegal referrals and kickbacks, and inappropriate certifications for services like hospice care. Individuals with information of any of these fraudulent practices can bring whistleblower cases under the False Claims Act, 31 U.S.C. § 3729 et seq. These cases are also known as qui tam cases and are brought in federal court on behalf of the government to recover money paid out as a result of such fraud.  31 U.S.C. § 3730.  In fact private enforcement of the FCA through qui tam cases recoups on average over 80% of all the money the government recovers annually from businesses defrauding it.  The whistleblowers (known as relators) who bring the cases receive up to 15-30% of what the government recovers as a reward.  31 U.S.C. § 3730(d). The California whistleblower/qui tam attorneys at Evans Law Firm, Inc. represent individuals with credible information of any type of fraud against the government, including fraud for false hospice certifications.  If you have credible information for a whistleblower or qui tam case, call Evans Law Firm, Inc. today at (415) 441-8669 or TOLL FREE 1-888-80EVANS (888-503-8267)

False Hospice Certifications

False certifications for government reimbursed services are one instance of healthcare fraud identified in whistleblower cases. Two recent examples of false hospice certification cases[1] illustrate the kind of actionable fraud that goes on in this sector of the health care field.

Example One

The U.S. Department of Justice (DOJ) and a State agency recently filed a consolidated complaint against a group of affiliated hospice agencies and parent corporations that the affiliated companies violated the False Claims Act (FCA), 31 U.S.C. § 3729 et seq., as well as State false claim laws.  FCA hospice cases generally involve certification issues; that is, on the question of patient eligibility for hospice care based on a six-month terminal prognosis.   In the r4eported case, according to the DOJ, “Defendants pressured staff at their local hospice agencies to maximize admissions and census through aggressive financial targets and incentives, while simultaneously discouraging the discharge of patients who were no longer eligible.  Defendants also failed to ensure that physicians who provided legally required and material certifications and recertifications of patients’ terminal illnesses received or adequately considered complete and accurate information regarding patients’ conditions.” According to the complaint, the hospice business allegedly failed to return Medicare and Medicaid payments they had received despite internal audits showing that some patients were not hospice eligible. The complaint also alleges that the defendants did not adequately train clinical staff to identify and assess terminal illnesses.

Example Two

The second example of a recent FCA hospice case is U.S. ex rel Drudging, et al. v. Care Alternatives, No. 18-3298, 2020 WL 1038083 (3d Cir. Mar. 4, 2020), where the Third Circuit Court of Appeals upheld the right of four former hospice employees to proceed with whistleblower allegations that their employer falsely certified patients for hospice care in order to receive government reimbursement under Medicare.  Conflicting expert testimony had been presented in the case about the patients’ eligibility. Defendant argued the difference of opinion proved there was no objective falsity.  The Third Circuit rejected that standard found that the difference of medical opinion meant that that the “falsity” of the claims was a triable issue.

Under Care Alternatives whistleblowers would not need to show objective falsity in order to proceed with their claims in these types of cases; disputing expert opinion would be enough to survive a summary judgment motion by defendant on the issue. The decision represents a victory for qui tam plaintiffs in cases where the medical necessity of a reimbursed procedure or service is the central issue.

Contact Us

If you or a loved one has information regarding a whistleblower or qui tam case of false claims for Medicare and Medicaid reimbursement for hospice patients, contact Ingrid M. Evans at Evans Law Firm, Inc. at (415) 441-8669, or TOLL FREE 1-888-80EVANS (888-503-8267) or by email at <a href=””></a>. Ingrid also handles other types of whistleblower cases including for bank fraud under The Financial Institutions Reform, Recovery, and Enforcement Act of 1989 (FIRREA/FIAFEA), securities fraud under the Commodities Futures Trading Commission Whistleblower Program and the Securities and Exchange Commission Whistleblower Program, the Internal Revenue Service Whistleblower Office, the FINRA Whistleblower Office or the California False Claims Act.

[1] Evans Law Firm, Inc. was not involved in either of the reported cases.

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