Caris Healthcare, LP
Outcome
Caris Healthcare paid $8.5 million to resolve False Claims Act allegations that it admitted hospice patients who were not terminally ill to meet aggressive census targets, directed nurses to document only negative findings and delete documentation of patient stability, overrode clinical staff objections to admit ineligible patients, and knowingly retained overpayments identified through internal audits.
Details
Caris Healthcare, LP — Systematic Admission of Ineligible Hospice Patients with Internal Cover-Up (2018)
Outcome: Caris Healthcare, LP paid $8.5 million to resolve False Claims Act allegations that it admitted hospice patients who were not terminally ill in order to meet corporate census targets, directed nursing staff to "chart negatively" and delete documentation showing patient stability, overrode clinical staff recommendations against admission, ignored internal audit findings identifying ineligible patients, and knowingly retained identified overpayments.
Caris Healthcare, LP is a for-profit hospice chain operating in Tennessee, Virginia, and South Carolina. The settlement, announced in October 2018, resolved allegations covering conduct from approximately 2011 to 2016.
The case is distinguished from typical hospice eligibility fraud by its documented internal corporate directives. Rather than simply failing to screen patients adequately, Caris actively directed its conduct in ways that compounded the fraud: management set aggressive patient census targets and pressured admissions staff to meet those targets; when nurses performing admissions assessments recommended against admitting a patient, those recommendations were overridden; nurses were explicitly instructed to "chart negatively" — to document only information suggesting the patient was declining and to omit or delete documentation showing stability or improvement; and at times, documentation affirmatively showing the patient was stable or improving was deleted from the medical record.
Additionally, when Caris was made aware of the ineligibility of specific patients through internal audits, through concerns raised by its Chief Medical Officer, and through the recommendations of its own nursing staff, the company did not refund identified overpayments to Medicare. Under 42 USC 1320a-7k, a provider's knowledge that it has received an overpayment and failure to return it within 60 days constitutes a separate False Claims Act violation — the "knowing retention" theory. Caris's failure to act on internal audit findings therefore converted what might have been administrative billing errors into additional layers of False Claims Act exposure.
The qui tam lawsuit was filed by Barbara Hinkle, a registered nurse who formerly worked for Caris Healthcare and had personal knowledge of the admissions and documentation practices. She received $1.4 million of the settlement as her relator share.
How Crucible Prevents This
Crucible clinical documentation integrity controls would prevent the deletion or alteration of contemporaneous nursing notes that document patient stability or improvement, maintaining an immutable audit trail of all clinical record modifications. A census-target monitoring module would flag operational pressure on admissions staff when census targets are being tracked as a performance metric by management, triggering a compliance advisory that links admission decisions to clinical rather than operational criteria. An internal audit response workflow would require that identified overpayments be reported to the government and refunded within the 60-day self-disclosure window under 42 USC 1320a-7k, preventing the "knowing retention" of identified overpayments that converts a billing error into a False Claims Act violation.
Don't let this happen to your organization. See how Crucible works.
See How Crucible Works