MEDICARE: HCFA Accuses Hospice Patients of Fraud
Concerned with growing evidence of Medicare abuse, HCFA hired private companies to investigate cases of terminally ill patients who live beyond the standard six month prognosis for hospice care, the Wall Street Journal reports. While some extensions are granted to the six month rule, enacted in the 1980s, longer survival "can be deemed excessive and can trigger an investigation." Robert Berenson, HCFA's director for health plans and providers, said, "We try to emphasize that not everyone has to die within six months; it is a judgment." Even so, he said that doctors must "know what the rules are, and that their best estimate of prognosis should be six months or less." A 1997 HHS memo warned HCFA to crack down on hospices, stating, "There has been less rigorous enforcement of the six-month prognosis requirement by the hospice industry, especially for various non-cancer diagnosed patients." The memo requested that HCFA make "hospice physicians more accountable."
Hospice Patients Dropped
In February 1997, a private company called United Government Services distributed letters on behalf of HCFA to a handful of elderly patients under the care of the Hospice of the North County in upstate New York. All the patients had lived beyond their six-month prognosis. The letter read: "You are not eligible for the Medicare hospice coverage," and "Medicare will recuperate the money that it inappropriately paid." One 87-year-old patient suffering from endometrial and breast cancer, who had survived four years longer than expected, entered a nursing home after she was dropped from North County as a result of the investigation. The nursing home charged Medicare almost twice the hospice's fee. According to a UGS spokesperson, North County was treating some of the wrong patients whose diagnoses "didn't meet" medical criteria for terminally ill status. "Our focus is the medical record itself and the prognosis of the patient," UGS's Joanne Houillon said, adding, "It wasn't a matter of us not being willing to cover these people because they lived too long." After UGS moved to collect the hospice's entire Medicaid reimbursement -- about $55,000 a month -- the hospice filed an administrative court hearing, where a judge ruled in the hospice's favor. The ruling declared that Medicare's six-month prognosis policy was "never intended as a hard and fast rule" and should allow for the "normal course" of an illness. "The fact that some patients 'exceeded those expectations does not indicate that a fraud was perpetrated,'" Administrative Law Judge John Stewart found. The fact that some lived longer, he said, "represents an achievement ... not an indica[tion] of fraud." According to Amber Jones, head of the New York Hospice Association, the six-month rule "doesn't fit" any longer, and she notes that the industry remains divided on whether the government should lengthen the time period or vary it for different medical conditions. Dr. Berenson said: "There were some problems identified ... in the early 1990s, which perhaps led to a somewhat aggressive oversight. (But) we are finding the balance" (Lagnado, Wall Street Journal, 6/5).