According to data released by the Centers for Medicare & Medicaid Services last week, Mississippi hospices discharged 20.6 per cent of Medicare patients alive in 2014. South Carolina ranked second in live deaths, with 18.3% of Medicare patients being discharged alive. Nationally, the average is 11%. “Mississippi is plagued by hospice fraud,” stated Chris Covington (assistant special agent, U.S. Department of Health and Human Services Office of Inspection General), who has been investigating Medicare fraud in Mississippi since 2013. The live-discharge rate of hospice, which offers end-of-life care to terminal patients, would be zero in a perfect world. Hospice advocates acknowledge that death is unpredictable and some mistakes are to be expected. Covington stated that one fifth of Mississippi’s patients are still alive, which means that many Mississippi’s hospices have been billing Medicare for care that they never provided. Covington stated that there was no other explanation for the high rate of live discharge than the fact these patients were never on hospice. “That’s why these people get discharged alive because they weren’t dying in any way.” Mississippi has a history of fraud in hospice care. The U.S. Attorney’s Office indicted or arrested nine individuals in connection with hospice fraud schemes worth nearly $15 million. Eight people have pleaded guilty so far. Officials from the government believe that more will be guilty. “It’s huge figures, lots and lots of money. “… And it’s still an issue,” Chad Lamar, Assistant United States Attorney for Northern District of Mississippi said. “More indictments? It’s absolutely guaranteed. It’s guaranteed. We are aggressively investigating hospice fraud in Mississippi. Covington stated that the project is far from over. Covington described each scheme as a “cookie cutter” and said that they are all run by a hospice owner who contracts with a runner to go door to door to find Medicare beneficiaries to sign up for their hospice programs. The runner will often offer incentives such as $50 gift cards and weekly visits with a nurse to sweeten the deal. They forget to mention that Medicare’s hospice program is only available for terminally ill patients. Patients are often shocked to learn that hospice is only available for patients with less six months left. He said that they are also shocked to learn how much Medicare has been charged by their hospice providers. “We see cases where Medicare has paid up to $35,000 in hospice benefits, and patients say immediately, “Well, they just come and clean the house” or, “They just come by to take my blood pressure,” Covington stated. “When caring for terminally ill patients, it is expected that the services you provide are complex. In these cases, Medicare is not really paying for what it gets,” Covington and Lamar said. A doctor must certify that the patient has less than six month to live in order to be eligible for Medicare. Instead of asking a patient’s usual physician, runners bring their patients to the hospice provider’s doctor, who will then sign off on the terminal diagnosis. Usually, this happens without the patient being aware. The incentive in Dr. Walter Gough, Jr., of Drew was a $14,000 per month financial kickback. According to Lamar, Gough’s story is an example of a typical hospice fraud scheme. Gough was employed by Andre Kirkland in 2010, co-owner of Revelation Hospice. May Gough, his wife, was hired to run the runner for $4,000 per month. According to court documents, Kirkland stole millions of dollars from Medicare between 2011 and 2013. Revelation had a 93% live discharge rate at the time Kirkland was arrested. Kirkland was sentenced last month to 48 months of home confinement and ordered by Medicare to repay nearly $5.5 million. Walter Gough was unexpectedly killed before he entered a plea. May Gough pleaded guilty, but was not sentenced. Patrick Pendleton was another runner who recruited patients for at most five hospices in the Mississippi Delta. Pendleton pleaded guilty to Medicare fraud and was sentenced for 40 months. Lamar stated that Pendleton’s employee overlap is the reason this fraud has grown in Mississippi, and specifically the Mississippi Delta. Many fraudulent hospice owners, like Andre Kirkland who was a nurse prior to opening Revelation, were able to commit fraud while they worked for other hospice providers. “There are many incestuous relationships among the hospice providers we have charged with fraud. It is common for employees to switch from one another and patients to be switched from one another. Lamar stated that doctors are willing to help. Covington refers to many of these programs as “mom-and-pop” operations. The ease with which they pop up is evident when you look at the number of providers in Mississippi. According to data from the Department of Health and Human Services, Mississippi had 65.1 hospice providers per 10,000 beneficiaries in 2015. In 2015, the national average was 31.3. According to CMS data, Mississippi had 108 hospice providers in 2014. This is the 12th most number of providers in the nation. However, Mississippi is 31st for population. Each state that has more hospice providers also has a higher population. California has 13 times as many hospice providers than Mississippi, with 499 in 2014. Florida was fourth in population, with only 42 providers. Covington also said that Mississippi’s high rates of live discharge are not the only indicators of fraud. Another indicator is the number patients who stay in hospice for more than 180 days. Medicare automatically approves a terminally ill patient for a six month stay in hospice. This can be extended or reassessed. Patients who are not terminally ill live longer than patients who are. Mississippi had 2,574 of the 15,004 patients in 2014. Mississippi was third for hospice stays exceeding 180 days, with 17.2 per cent. According to data from the Centers for Medicare & Medicaid Services, only South Carolina (18.4%) and Alabama (17.8%) ranked higher. The Medicare payments are larger because of the long stay in hospice. According to CMS data, Medicare spends on average $14,361 per beneficiary of Mississippi’s hospice program. This is more than any other state except South Carolina. Even those in the hospice industry that had not been following fraud investigations were alarmed by Mississippi’s figures. Joy Cameron, vice-president of policy and innovation for the Visiting Nurse Associations of America said that Mississippi’s numbers were so alarming that her organization reached out to Centers for Program Integrity at the Centers for Medicare & Medicaid Services to conduct a strategic data-based targeting of all hospice providers in order to determine if they are providing the right care. Cameron stated that while we don’t want the entire industry to be painted, we do want them to strategically identify those in our industry who are causing us all to look bad. Although the Centers for Medicare & Medicaid Services did not confirm that such conversations took place, they confirmed that fraud and high rates of live release. Many hospices believe that longer stays and higher live discharge rates are a result of the growing number of hospice patients. CMS officials stated in an email that they believe these same factors could be indicative of fraud and warrant investigation through Medicare’s program integrity analysis of health benefits at this level. CMS was backed by some hospice advocates who suggested that culture can also play a role in high rates of live discharge. According to Jamey, the executive director of Louisiana Mississippi Hospice & Palliative Care Organization, people might be less familiarized with hospice in communities that have higher levels of poverty or lower educational attainment. Family members are more likely to call an ambulance to rush a loved one to the hospital when they know that their loved one is near death. A live discharge is given to a patient who is transferred from hospice into a hospital. This is even though it may be hours before their death. Governor. In 2014, Phil Bryant signed House Bill 1004, also known as the Physician order for sustaining treatment. This law allows terminally ill patients to keep an official record of what life-sustaining treatment they are willing to receive in an emergency. Boudreaux stated that he was disconcerted by the numbers and his organization would launch a deep dive into state hospice data to find an explanation. It was a surprise to us. Boudreaux stated that although we knew about the high rates of live-discharge in Mississippi, we didn’t know it was one of the highest in the nation. Covington stated that this trend is likely to change. According to data from National Institutes of Health, Mississippi’s live discharge rates have fallen from 40.5 percent in 2010 to just 30.5 percent over the past four years. Live discharge rates nationwide have dropped almost as much, from 18.2 percent in 2010 down to 11 percent in 2014. Mississippi continues to winnow its hospice providers. In fact, the rate of live discharges has dropped from 89 per 10,000 residents in 2010 down to 65 per 10,000 in 2015. Covington stated that this decline is due to the efforts of his office and the U.S. Department of Health and Human Services, who have worked together since 2014 to root out Medicare fraud and hospice fraud in Mississippi. Covington stated that “we think it’s trending, and we think it’s a growing industry for fraudsters,” so his organization is interested in any cases of hospice fraud. It has been more difficult to open a Mississippi hospice program. 2013 Governor. Bryant signed House Bill 411, which established a one year moratorium on the opening of new hospice programs, into law in 2013. In a statement, the House of Representatives stated that the bill was intended to “reduce fraud, provide better hospice care, and save money.” Data released by the Centers for Medicare & Medicaid Services were gathered from a survey of 4,015 providers of hospice services regarding their service to Medicare beneficiaries in 2014. This is the most recent year for which data are available. According to the Centers for Medicare & Medicaid Services, the release of the data is part a continuing effort to improve transparency within the department. In the accompanying press release, Niall Brennan, chief information officer for the Centers for Medicare Services stated that CMS believes greater transparency in data will lead to a better functioning health care system that leads to better care and smarter expenditures.