The Trump Administration is going after Medicare and Medicaid fraud. A man who defrauded Medicare out of more than $547 million for unnecessary genetic cancer tests was recently captured in the Middle East and is being returned to the U.S. to stand trial. The growing use of skin substitutes has been blocked after some doctors began charging more than $20,000 an inch for unnecessary wound care. One clinic owner was arrested after billing Medicare for nearly $300 million for skin substitutes, often charging more than $1 million per patient.
It is about time that federal officials took health care fraud seriously. Medicare fraud has been hiding in plain sight for decades. Another common example is Medicare hospice fraud. California is the epicenter of hospice fraud investigations but not the only state where it occurs.
Medicare’s hospice program is designed to provide palliative care for terminally ill patients who are in the last six months of life. The idea is to make terminally ill patients comfortable in their final months, while ceasing therapeutic care. We know some hospice care is fraudulent because too many seniors enrolled are outliving their six-month window. In addition, palliative care should not run into the tens of thousands of dollars. The following is what I wrote earlier:
According to House Oversight Committee, the average hospice cost per Medicare beneficiary is about $13,000. Hospices in LA County billed an average of about $29,000 while one hospice bill was $74,000 per patient. One doctor’s Medicare provider number was used to bill Medicare for 76,000 claims over a three-year period totaling nearly $600 million.
The Washington Post reports that hospices worry patients will be unfairly punished amid fraud crisis. Purportedly, tightening regulations could put patients at risk. The following is an anecdote WaPo wrote about:
Mark Vantrease regularly sees his Vietnam War buddies over breakfast, attends his grandchildren’s Little League games, and, when he’s up to it, tends to his lush front-yard garden, which is dotted with shells retrieved from his abalone-diving days.
Time is precious for him. Last year, doctors told the 76-year-old former truck driver that a combination of heart failure, lung disease and liver damage had left him with only six months to live. “That was about 11 months ago,” Vantrease said in a May interview, smiling at having, for the moment, cheated death.
Mr. Vantrease did not cheat death. More likely, the hospice program cheated Medicare. Or perhaps it is more accurate to say Mr. Vantrease was enrolled prematurely in the hospice program, although the care he is receiving appears to be beneficial. A family member was admitted to a nursing home when she became too frail to live at home. In her 90s, she was in relatively good health for her age. The nursing home soon asked permission to place her in hospice care, emphasizing the additional services she would receive for free. She lived two more years, not six months.
There are about 7,000 hospices approved to provide Medicare services nationwide. Medicare patients using hospice reportedly saves Medicare an estimated $3 billion per year by providing palliative care rather than continued treatment. But left unchecked, hospices can also become a source of fraud that costs taxpayers rather than saving money on hospital care. In 2022 there were an estimated 5,800 hospices in the country, 2,800 of which were in California alone. An earlier investigation by CBS News found that nearly half of the hospices in Los Angeles County had red flags that should have prompted additional scrutiny. People were recruited, sometimes even placed in hospice care without their knowledge. However, opinions can differ about what constitutes an ethical hospice and ones abusing the program. More from WaPo:
Hospice administrators in good standing have already found themselves in the crosshairs: A Washington Post investigation in June found that the federal government’s new anti-fraud task force has already suspended licenses for 43 legitimate hospices.
Officials report that the program is growing. About half of Medicare decedents were never enrolled in hospice. Nearly half of hospice patients spend about two weeks or less due to referrals late in their illness. Five years ago, the average length of stay in Medicare hospice was 92 days. However, Medicare hospice patients are increasingly outliving their six-month life expectancy window. Nearly one-in-five Medicare hospice patients discharges are alive, some (6%) with an extended prognosis.
The Medicare hospice benefit is a great program. It just needs better supervision, and more effective clawback provisions when unscrupulous hospice operators enroll ineligible seniors.
Read more about the Medicare hospice program:
CMS Hospice Monitoring Report
Washington Post: Hospices worry patients will be unfairly punished amid fraud crisis