DOJ Opts to Intervene in Whistleblower Case Against United Healthcare

In a recent False Claims Act case filed in Colorado, the federal government has decided to intervene after engaging in a preliminary investigation of the relator’s claims. The government, which intervenes in approximately 25 percent of all filed False Claims Act cases, will join as an active participant against Evercare Hospice and Palliative Care – a group accused of engaging in fraud against Medicare and Medicaid. There are actually several lawsuits ongoing against the group, which is run by parent company United Healthcare – also named in the suit.

Details of Case Against Evercare Hospice

Healthcare fraud is one of the most widely-litigated matters under the False Claims Act. In today’s case, nationwide hospice provider Evercare is accused of circumventing federal guidelines with regard to reimbursement for services rendered to patients facing terminal conditions. Under current federal Medicare guidelines, a patient must meet certain criteria before becoming eligible for round-the-clock palliative care. Failure to meet these guidelines, or falsely certifying a patient as eligible, can trigger liability under the False Claims Act, provided the provider intentionally defrauded government healthcare programs.

Under Medicare Part A guidelines, a palliative care provider like a hospice center can only apply for reimbursement on behalf of Medicare if the patient is deemed to be suffering from a “medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course.”

Once certification is approved, that patient is eligible for a 90-day stay in a palliative care center, which is renewable in 90-day increments for the duration of the patient’s life. Providers must maintain a daily log of the patient’s condition, which must contain “correct clinical information.” As long as the patient remains eligible for hospice services, the facility will be reimbursed at a per diem rate

Evercare operates its hospice facilities in eleven states: Alabama, Arizona, California, Colorado, Georgia, Maryland, Massachusetts, Missouri, Ohio, Texas, and Virginia. According to the complaint, it does not actually run or manage these skilled nursing facilities, but rather contracts with providers for the provision of end-of-life care. While not directly responsible for direct patient interaction, Evercare was responsible for setting up business protocols and standards for its centers, thus rendering it liable in the event of misconduct by staff.

According to the allegations, since 2006, Evercare has consistently admitted ineligible patients, accepted reimbursement for these patients, and failed to refund the government overpayments for ineligible palliative care. Ineligible patients, which Evercare certified were eligible, included those with dementia, cardiac or pulmonary irregularities, and debilities that, while serious, were not likely to lead to the death of the patient within six months.

The complaint further alleges that staff was provided bonuses for obtaining, certifying, and admitting ineligible patients. Further, staff was allegedly threatened with demotion or termination for failing to meet admittance criteria. As well, Evercare is alleged to have employed inexperienced staff members with little working knowledge of the intricacies of palliative nursing care.

Contact a Reputable Whistleblower Attorney Today

If you are aware of Medicaid or Medicare billing fraud, we encourage you to contact us today. For more information about how you can commence a whistleblower lawsuit, contact Berger Montague today.