In 2014, the federal government decided to intervene against Evercare, now known as Optum Palliative and Hospice Care, in two whistleblower lawsuits which alleged that the hospice care provider had claimed Medicare reimbursements for patients who were not eligible for the type of care they received.
Two years later, a settlement has been reached, by which Optum Palliative will pay the federal government $18 million to resolve the False Claims Act allegations, which were initiated by two former Evercare employees, whistleblowers Terry Lee Fowler and Lyssa Towl. The whistleblowers will receive a reward that could go as high as 30% of the multi-million dollar recovery.
Lyssa Towl and Terry Lee Fowler Whistleblower Suit Alleged Medicare Fraud
Hospice care is covered under Medicare for patients who are terminally ill, but Evercare billed the federal program for the care of elderly patients who, albeit often incurable, did not fulfill the requirements for Medicare's hospice benefits. In order to be eligible, a patient must have a life expectancy of six months or less.
The palliative care in question is a type of end-of-life care which is designed to comfort the dying. It is mainly focused on reducing pain and stress, as well as mitigating symptoms. When they are admitted into the hospice care system, patients can no longer receive specific treatments for their illness under Medicare.
Ineligible Patients & Pressuring Physicians among Whistleblowers’ Medicare Fraud Allegation
According to the lawsuit, Evercare not only admitted ineligible patients into the program, but they also pressured health professionals to admit and retain them, and systematically ignored physicians’ decisions to discharge patients. The whistleblowers reported that the company “targeted for admission ineligible elderly patients with conditions like debility, dementia, Alzheimer’s and cardiac or pulmonary irregularities that while serious were not likely to lead to the death of the patient within six months, thus allowing the defendants to keep these types of patients on their hospice census for more than six months, if not several years.”
Because hospice care eligibility is not based on a certainty; as no one can know exactly when a patient is going to die, what Evercare allegedly did was pretend that they truly believed the ineligible patients were terminally ill. When the patients stayed in care for longer than six months, they could, in theory, simply argue that they had made a mistake in predicting life expectancy. When doctors established that patients were not terminal and should be discharged -according to the allegations - Evercare simply looked the other way according the False Claims Act qui tam lawsuits.
Hospice Abuses Threaten the Vulnerable says DOJ’s Benjamin Mizer
Commenting on the recent settlement, Principal Deputy Assistant Attorney General Benjamin C. Mizer, head of the Justice Department’s Civil Division said, “Our seniors rely on the hospice program to provide them with quality care, dignity and respect when they are terminally ill and need end-of-life care. It is, therefore, critically important that we hold accountable those hospice providers that bill for medically unnecessary services in order to get higher reimbursements from the Medicare program. Such abuses threaten a vulnerable population and jeopardize this important benefit for others under the program.”
In a statement following the government's settlement with Optum Palliative and Hospice Care, formerly known as Evercare, Special Agent in Charge Steven Hanson of the Department of Health and Human Services’ Office of Inspector General emphasized the government's strong resolve to fight the exploitation and overbilling of Medicare by health care providers: “We will continue to vigorously investigate health care companies that put their own profits above the medical needs of patients to ensure that companies bill Medicare only for reimbursable health care services.”
Over the last few years, with the help of several hundred whistleblowers, the False Claims Act has been an invaluable tool in exposing this type of misconduct within the health care system. In 2015 alone, the government recovered $1.9 billion for taxpayers from False Claims Act cases in the health care industry.