Hospice is a Medicare benefit if you have Medicare Part A (hospital insurance) and meet all of these conditions:

Your hospice doctor and your regular doctor (if you have one) certify that you are terminally ill (with a life expectancy of six months or less).

You accept comfort care (palliative care) instead of care to cure your illness.

You sign a statement choosing hospice care instead of other Medicare-covered treatments for your terminal illness and related conditions.

Medicare-certified hospice care is usually given in your home or other facility where you live, like a nursing home. You can also get hospice care in an inpatient hospice facility. Original Medicare will still pay for covered benefits for any health problems that are not part of your terminal illness and related conditions. Once you choose hospice care, your hospice benefit will usually cover everything you need.

For hospice, you pay nothing for care. However, you pay a co-pay of up to $5 for each prescription for outpatient drugs for pain and symptom management. You may pay 5% of the Medicare-approved amount for inpatient respite care and you may have to pay for room and board if you live in a facility (like a nursing home) and choose to get hospice care.

Hospice is an important benefit for the Medicare population. Hospice fraud threatens this benefit for all beneficiaries. Scammers are getting beneficiaries to agree to hospice care even though they do not qualify for the benefit, i.e., they are not terminally ill. Hospice fraud occurs when Medicare Part A is falsely billed for any level of hospice care or service. Hospice fraud is lucrative. Fraudsters lie and cheat to steal beneficiaries’ Medicare information and to have Medicare beneficiaries sign consents to enroll in hospice. A beneficiary who speaks little or no English is especially vulnerable to sign a consent, not knowing what he/she is signing.

Hospice fraud is potentially more dangerous for beneficiaries because hospice care provides palliative care only. This means the focus of care switches from curative care (treating the illness) to comfort care (quality of life and ease of pain). For example, when a beneficiary is receiving chemotherapy treatment for cancer and their coverage switches to hospice, the chemotherapy is no longer a covered treatment as it is a curative treatment. While the beneficiary can discontinue their hospice benefit at any time, this may prove difficult if they are dealing with a fraudulent hospice enrollment. While waiting to be disenrolled, the inability to receive lifesaving or curative treatment could be detrimental for the beneficiary.

Report potential hospice fraud, errors, or abuse if:

You or someone you know was falsely certified as being terminally ill—that is, with a life expectancy of six months or less if the disease runs its normal course.

You were enrolled in hospice without you or your family’s permission.

You find out someone is falsely certifying or failing to obtain physician certification of plans of care.

You were offered gifts or incentives to receive hospice services or to refer your friends and family for hospice services.

You see on your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) that you were billed for a higher level of care than was needed or provided or for services not received.

You hear about an assisted living facility and/or nursing home residents being targeted for hospice services even though their life expectancy exceeds six months.

You come across marketers using high-pressure and unsolicited marketing tactics of hospice services.

You receive inadequate or incomplete services, including, for example, no skilled visits in the last week of life.

You are provided/offered gifts or incentives, including non-covered benefits such as homemaker, housekeeping or delivery services, to encourage you to elect hospice despite not being terminally ill.

You hear about hospice beneficiaries being abused or neglected by a hospice worker.

You hear about a hospice worker stealing a beneficiary’s medication.

You are kept in hospice care for long periods of time without medical justification.

Hospice fraud can be reported to your state Senior Medicare Patrol. In New Jersey, it is the Senior Medicare Patrol of New Jersey, c/o JFS of Middlesex County, 219C Blackhorse Lane, North Brunswick, NJ 08902. Call the hotline at 877-SMP-4359 or our offices at 732-777-1940. Also, visit our website at www.seniormedicarepatronj.org  to learn more about hospice fraud and other frauds related to Medicare.

Charles Clarkson, Esq. is the project director of Senior Medicare Patrol of New Jersey.