Hospice Owner Fights Rising Medicare Debts

Unfunded Congressional Mandate Sticks Hospice Owner Bobbie Fleming With $3 Million Bill

(CBS)  Registered nurse Bobbie Flemming drives about 1,000 miles a week around the Mississippi Delta, making dozens of house calls.

But Fleming, a hospice owner, is not out to save lives. Her goal is to help her terminally ill patients die in peace, by offering, as she says, "Just a small amount of comfort and compassion on this end-of-life journey."

But there's a problem: 11 years ago, Congress mandated that terminally-ill patients are entitled to unlimited hospice care - but Medicare only pays the hospices for six months' worth, CBS News correspondent Thalia Assuras reports.

So when the federal government realizes its been paying for people like throat cancer patient Willie Ross for well over six months, Medicare demands its money back - plus 12 percent interest.

Flemming's current bills show she owes more than $3 million.

She says whatever funds she has go to purchasing drugs, buying medical equipment and paying staff salaries. And she has no intention of denying her patients treatment.

"I'm not the one to say because you're not dead, I'm just going to dump you," said Flemming. "It's not in me to say that."

Medicare declined to comment to CBS News, citing a lawsuit on the issue. But it has offered Flemming a choice - either pay up or declare bankruptcy.

"I've always done the right thing about end-of-life care," said Flemming. "I'm going to continue to do it and someone is going to eventually hear this."

Flemming recently took her case to Capitol Hill with other hospice owners, asking Congress to freeze their debts until it can come up with a way to pay for extended hospice care.

Until then, Flemming said she's not going to play God by turning away patients just because they don't die on schedule.

Sue Medicare. With Interest, of course. They are obviously out of compliance with the federal mandate. Require them to pay or go bankrupt. It''s only a short haul anyway.

[vasocwkr]

This appears to be misrepresented. If an individual continues to meet hospice criteria, and recertification''s are obtained as required by Medicare (first 2 benefit periods are 90 days in length, subsequent benefit periods are 60 days in length), there is no limitation of benefit periods. The problems arise if the individual is no longer hospice appropriate or if necessary documentation is not obtained. There appears to be vital information missing from this story...based on what is given, this information is inaccurate.

[reba_1205]

Kudos to Thalia for caring for the sick, the forgotten. As I struggle to fight injustice in my own community (the public school system in which I teach), I am reminded how minimal workers'' rights are. Thalia, a caregiver working in the trenches, should be given the tools and financial support necessary to implement end-of-life care. Your patients must adore you for the dignity and respect you afford them.

All stories have two sides: Medicare should have clarified their position on air if they have nothing to hide. Billing Thalia personally 3MIL is so despicable it''s laughable. Shame on you, senseless bureaucrats!


Thalia, you have re-energized me to continue fighting the good fight. I wonder if nationalized health care might address some of these unfriendly policies?

[inderwies]

This story falls short of describing the whole picture. The Medicare Hospice benefit is just that. Providers that choose to follow the prescribed guidelines have little trouble falling within their CAPS! Hospice was never intended to be a benefit for chronic care management. As long as providers follow established guidelines, the benefit has much latitude to provide excellent end of life care at little or no financial risk to a provider. I may disagree with Medicare on some things, but these providers are absolutely wrong in how they are addressing and potentially jeopardizing a very important benefit that does work and has serviced so many families since Congress made the Medicare benefit permanent in 1986!
Congress did mandate that terminally-ill patients are entitled to unlimited hospice care as long as the physician can certify that the illness is terminal and the hospice can demonstrate a progression of the disease, Hospices that go over the 180 day cap need to take a closer at their certification process and examine their own internal processes which resulted in exceeding these averages. What concerns me most is that Congress and Medicare are looking the system as a whole and contemplating sweeping changes that could negatively impact a much valued benefit as a result of poor practices by a few. The Medicare benefit works well when done right and managed as it was intended to care for terminal not chronically ill patients!

[wogerwabbit]

The Medicare benefit works well when done right and managed as it was intended to care for terminal not chronically ill patients!

Posted by inderwies at 09:17 PM

Have you ever known anyone terminally ill? A bag of bones can live for a long time if they have the will. Perhaps in your system we should make use of the not yet dead beats. Soylent Green anyone?

[mbburch06]

And there are some people out there who still think the solution to our healthcare problems is MORE GOVERNMENT... HA!

[interested61]

I was surprised by the misinformation given in this segment. There is no limit to the hospice benefit, but there is a CAP, which is designed to prevent abuse of the system. Please reinvestigate this story and research the facts. Talk about how congress is wanting to cut current benefits, which will hurt so many who could truly benefit from hospice, not about providers who are having to pay back because of possible mismangement.

[lochlan-2009]

"Congress mandated that terminally-ill patients are entitled to unlimited hospice care - but Medicare only pays the hospices for six months'' worth"

Only in D.C. can this kind of logic be acceptable. The representatives should pay for it out of their pay, plus 12%.

[gaylegeng]

I am saddened and disappointed in CBS reporting, this report needed to have been further investigated. Hospice Medicare expenditures are rising, in part due to the rise in those needing care and due to the benefits being publicised. Medicare allows for appropriately, extended care if you meet the criteria of having a terminal diagnosis. The Hospice Benefit is not intended to be a primary care giver, nor care for those with Chronic Illness. There are Hospice agencies who will risk payment to increase numbers when providing care outside of the guidelines. Responsible Hospice Agencies follow the Medicare guidelines, provide wonderfully compassionate care, and on rare occassion must discharge a client whose condition stablizes or no longer meets the criteria. Please consider a follow up report that will provide a more accurate depiction of Hospice Care and perhaps investigate why Medicare would expect repayment for the specific services provided by the reported agency, perhaps the services fell outside of the intended Hospice Benefit- without the specifics you do not know.

Hospice payment for care provided outside of the benefit is not the responsibility of the Beneficiary, but the Hospice Owner- this report has upset clients and families of our Hospice, siting " the fear thaty they themselves would have to pay back", which is of course, not the case- the Agency Owner would be liable.
Administrator of a Hospice Program in the Midwest.

[blewi-2009]

This is grim news for anyone with a terminal illness or a loved one who is terminally ill. Hospices provide invaluable support -- medical, emotional and spiritual -- at a cost that''s far lower than traditional doctor and hospital care. No one can predict exactly when someone will die. As long as a terminal illness can be documented, people have a right to the kind of care they can get in a hospice -- and hospices should have the right to provide it!

[april3373]

I applaud CBS for doing this story. I work for a hospice in Oklahoma, where more than 40% of hospices are over cap. At our hospice, we follow Medicare''s guidelines for admission - we are careful to admit only patients who meet the guidelines. Although we follow the guidelines, we''re still over cap. Also, in response to one of the comments - it''s not possible for a hospice to bill Medicare for services that fall outside of the benefit. I''m not sure where the reader came up with this.

Thank you CBS for providing an accurate story and bringing attention to an issue that urgently needs to be addresssed.

[nellieb1229]

If hospices do not get some relief, many will have to close. When hospices close, people suffer -- patients, family members, hospice employees, etc. The sick and elderly seem to always be the first ones that our government penalizes whenever there are money cuts to be made. For example, the Medicaid PLAD program (Poverty Level Aged & Disabled) was completely abolished while young working-aged people still qualified for several kinds of assistance. Please support this bill and don''t let Medicare get away with sucking the life out of hospices one dollar at a time!

[sadiemariah]

Unless and until you have a loved one in hospice, you do not understand its importance and value. The opening of this story says it all: Hospice is a huge financial savings to Medicare and an immeasureable value to the person in hospice AND their families. Instead of this being a win-win situation, Medicare has penalized everyone involved. Typical bureaucracy unfortunately that cannot recognize a good system but instead is destroying it. Ever been to an emergency room? Ever taken an elderly loved one to an emergency room? Think about it. Where would you prefer your dying loved one to be? I''ll take hospice givers like Bobbie Flemming any day.

[darlinmommy]

I''m a Hospice Nurse for a company in North Carolina. Our company recently had to file bankruptcy in order to stay afloat. We actually went through reorganization in order to stay in business. We have been in business for many years and have had loans through a Financial Institution approved by Medicare. For years, the company I work for have been making payments on a loan with 12% interest in order to pay back the moneies owed to Medicare. We paid them on time and even more than the payment in order to pay down the priciple. This year they decided to pull out of our loan. This was like if you went to by a car, financed for 5 years, and after 2 years the bank decides they don''t want your business anymore and repo your car. You cannot give any patient an absolute pronosis as to when they will die. Everyone is different. Medicare sets the guidelines as to who we can admit and now they want to decide when they can die. If you don''t die in 6 months, the hospice agency is taking care of you for free. No wonder these agencies are turning to bankruptcy, or worse,out of business. People are living longer these days and more and more Hospice agencies are needed. It is cheaper for a patient to die at home rather than a Hospice or Nursing Home Facility. Medicare needs to way these options. Thanks for this Forum. Go Hospice Nurses.

[karenchpn]

The hospice cap is in no way tied to any individual patient, nor are demands for hospice pay back tied to any individual hospice''s performance on audits regarding their ability to determine a patient''s "appropriateness" as implied by some of the above misinformed responses. I am a Certified Hospice and Palliative Nurse who has been working as expert in hospice regulatory compliance for many years. My company has received a huge cap demand letter despite never having received a survey deficiency and having patient eligibility denial rate of 0.1% by Medicare. We have even been verbally commended and invited to join an advisory panel by Medicare''s fiscal intermediary for our interpretation of eligibility guidelines and our documentation of such. I would like to invite the uninformed or misinformed commentators which are impling that any company with a cap problem must be doing something illegal or unethical to compare their hospice credentials, experience, and survey/audit performance with those of my company and myself.

[keepbleeding]

Let''s see, you''re dying, but don''t die within the 6 months, so your provider either stops taking care of you or continues and gets an astronomical bill from Medicare ??? So relieved the government is taking care of the dying in this country. Makes me sleep better at night, knowing we are all guaranteed death, and have this rainbow waiting for us. Let''s die in the hospitals, it''s so much more "homey" and genuine!!! When will the bureacrats stop thinking of their pockets, and get their head out of their *****? Phenomenal empathy !!!

[slwknjns1]

I would like to thank CBS for bringing this problem to the public forum. Most people would never hear of this because it is a problem going on behind the scenes, that is until someone like you has the guts to report it. I have worked in the hospice industry for over 10 years and the company that I work for does not admit patients that are not appropriate according to Medicare guidelines. However just because they meet the guidelines does not mean they die on the medicare schedule. We are also over the Medicare cap just like the company in this article. If this was a problem of just a few hospices going over the Medicare CAP you could say maybe they were doing something wrong however this is a growing problem across the United States now effecting hundreds of hospices in over 25 different states. I truly do not think that many different agencies are doing things wrong. Again thank you CBS for helping. Also thank you Bobbie for having the guts to stand up and say we are not going to dump patients just because they don''t die when our govermnt says they should!!!!!!

[neg1920]

CBS would be providing a service to its viewers to do further investigation of hospice care and the Medicare Cap. The story, as reported, is a distortion of the Medicare Cap issue. CBS owes its viewers accuracy in its segments. The segment was emotionally charged and highly inaccurate. Please do another segment with the facts. There are a multitude of hospices across the country with no cap problems. Investigate and report accurately please.

[alphansg]

I can sympathize with Ms Fleming because I too am a R.N. came back home to Mississippi and worked with the population that I love the most the elderly and disabled of this great state that educated and trained me After many years of travel I decided to open my own hospice. At the present time we have no CAP issue, so I could give my support on any side of the issue. I chose the side of Bobby Fleming. We have had patients that because we were added to the equation of thier care are living longer,instead of a decline that was rapid in its descent, we helped to slow march toward death. Time given to say goodbyes, apologizes and never spoken I love yous. Some of the commenters say maybe Ms Flemming is paying for things outside of the hospice benefit allowance. I have paid for sitters that could not be furnished by caregivers so that the primary caregiver could work at least parttime to pay thier bills. Medicare says I don''t have.My conscience says that I must. Some of the larger corporations do not have the emotional investment that a mom and pop may have, they may have 10 medical directors, a home health attached and unlimited referral sources to off set thier cap.It would be good to investigate all the facts as one commenter suggested. Especially the discharge rate of people who are still eligible but are released from a program of a benefit they worked thier entire adult life to benefit for. We are here to help easy the passage as much as possible and make it beautiful. Join us.

[alphansg]

Sorry for some of the typos had to get it under 1500 characters which is pretty hard to do when something is so close to your heart:):):):)

[dave31302]

Kudos to Ms Assuras for the courage to report on the unfunded end-of-life care mandate. Bobbi Fleming is not alone; many other good hospices are also being hit by devastating cap demands. CMS doesn''t publish data, but best guess is 20% of freestanding hospices will receive demands from CMS for 2006 refunds of $300 million, 50% more than 2005. Bobbi said it well: hospices don''t have the money - they spent it 2 years ago caring for eligible Medicare beneficiaries, who are also their neighbors. This is not about hospices doing something wrong. This is about our dying parents and grandparents who earned the right to receive the care they paid for their entire working lives, and to die in their own good time.

Hospices offer the Greatest Generation the choice of dying at home, in dignity, free of pain and surrounded by their families. We should be celebrating the patients who outlive expectations, not punishing the hospices that care for them.

[skiergordo]

Some are obviously not familiar with the hospice benefit. Here are some FACTS.
1. In 1983 Medicare created hospice to save government funds spent on ineffective curative treatments for terminally ill cancer patients. They imposed individual and agency CAP%u2019s just in case it didn%u2019t work.
2. In 1998 Medicare found hospice VERY successful, saving billions, and dropped the individual CAP, expanded it to non-cancer diseases, and required agencies to serve them as long as the matched the symptom criteria. But they left the agency CAP.
3. Many lived longer since few diseases are as aggressive as cancer. The result is an artificial limit that is impossible for an agency to meet unless they violate the regulations and human decency with early discharge! Thus CAP issues appeared.
4. Hospice saves the government over $2,000 per patient. A hospice patient costs the government about $27,000for 6 months. One day in the hospital is $10,000 A DAY!

Every month dozens of hospices without a CAP suddenly get a demand for millions of dollars. Once you REALLY understand and the regulations, you see it is impossible to provide care and NOT have a CAP eventually.

Dozens of hospices who have a CAP problem are closing their doors each month, reducing the availability of hospice in their community. Write your Congressman and Senator TODAY and urge passage/inclusion of the PATH Act of 2008.

[darnedsocks]

THIS IS B.S.! MEDICARE NEEDS TO PONY UP AND PAY FOR END-OF-LIFE HOSPICE CARE FOR THE TERMINALLY ILL UNTIL THEY CROAK! IF MEDICARE WANTS TO SAVE MONEY, PERHAPS THEY SHOULD MAKE SURE THEY ARE NOT PAYING FOR THE CARE OF "ILLEGAL IMMIGRANTS"! THAT WOULD SAVE BILLIONS!

[dcforhospice]

I also work for Hospice in rural Oklahoma. It saddens me to see how this issue has become so divided. I have often asked myself who will care for the dying if we can no longer afford to stay in business. Our hospice has hit the CAP and has had the courage to also stand up for what we know to be right and in the best interest of those dying. Just this week I went to a patients funeral and was reminded how each moment is cherrished for families we serve. Many wish for more time they do not have and would be saddened to see that living more than Medicare allows has put such a burden on the hopsice that served them. I think until you have walked in a patient or families shoes how can you know how important one more day, week or month of life be when hospice has improved the quality at less cost to the government. I truly feel blessed every day knowing we do the right thing. Yes we have patients who get well enough to no longer need our service and we rejoice at those moments. Sadly most die, with some taking longer than Medicare allows. I applaud CBS for featuring the human side of death that may some day become lost if we do not stand up for those dying. After someone dies do we still hear their need? All some hear is silence and continue on. It would be great to get the story from the hospice patient faced with their hospice closing because Medicare does not hear the need because they did not die soon enough.

[peanutsgigi]

The cap is not about a few providers admitting ineligible patients as some would insist. It is a provider regulation that is now inconsistent with an eligible patient''s unlimited benefit. The CMS change to the benefit in 1998 created a different picture of the typical hospice patient--no longer short stay cancer patient. CMS began to actively promote hospice in 2000 and last year the Duke Study confirmed that hospice is "the rare situation whereby something that improves quality of life also appears to reduce costs.%u201D As a certified hospice and palliative care RN, I am glad that the hospice that provides care for my 106 year old grandmother in another state has not chosen to "manage" their cap by discharging a clearly eligible patient because she has lived too long. Thanks for bringing the issue to a very public forum for discussion.

[prohospice]

Reponse to neg1920 - yes there may be hospices that don''t have CAP issues right now, but what about the many hospices that ARE having Cap issues and that are going out of business because Medicare has sent them a bill DEMANDING payment for millions? I don''t see how it''s right for Medicare to request that Hospices pay millions of dollars back to them. This money has been spent on patient care!! I agree with darnedsocks maybe our gov''t should stop caring so much about the illegals in this country and focus on our aging citizens!

[prohospice]

Reponse to neg1920 - yes there may be hospices that don''t have CAP issues right now, but what about the many hospices that ARE having Cap issues and that are going out of business because Medicare has sent them a bill DEMANDING payment for millions? I don''t see how it''s right for Medicare to request that Hospices pay millions of dollars back to them. This money has been spent on patient care!! I agree with darnedsocks maybe our gov''t should stop caring so much about the illegals in this country and focus on our aging citizens!

[l7201613]

Everyone is entitled to their own opinions. I work for this hospice as a office manager and know for a fact that paperwork is filled out correctly because you cannot bill for any services without proper documentation. Trust Me when I say Ms. Flemming is a "stickler" when it comes to accurate documentation and proper procedure of rules and regulations. She not only has compassion for her patients she has it for her employees. Government is trying to calculate death timetables and there is no such thing. We all know only one person holds all the markers when our time is up. Many hospices in our areas have closed and left employees without pay. Although Medicare has put this burden on Ms. Flemming we have continued to work and receive our payroll. At times it has been late but nevertheless we received it and she hasn''t thrown her patients or employees out on the street. Continue the fight Ms. Flemming you will be blessed many more times than the government has control over. The government should quit changing the rules when they run short on money. These people have paid their hard earned dollars and deserve respect and dignity until their days are over here on earth. Thank you for the job and the opprotunity to work for such a dedicated company. sign me a Laurelite

[jgodwin5]

It''s not hospices with a CAP problem that are doing something wrong. Many hospices don''t have CAP problems becuasue they discharge patients after 6 months if they don''t die. Some tell patients that Medicare only covers 6 months of service and others just admit "to soon" and discharge quickly to "steal the CAP." If you really understood CAPs you would see that the people with CAP problems are doing the right thing...taking care of people that qualify for hospice until the day they die. That may be in 3 months, six months, or maybe a year, but it''s on God''s timetable. Keep doing the right thing and it will payoff in the end.

[jgodwin5]

VASOCWKR---YOU ARE AN IDIOT!!!Medicare does not look at a case by case basis to see if patients were appriate. You can have 100% appriate patients with great documentation to that affect and medicare''s going to day "so what, pay us our money back." It''s a numbers game to them.

[chasdh]

Hospice is a wonderful program and I have seen it help many people. I love my job with hospice and I dislike seeing a hospice punished for doing the right thing and taking care of a terminally ill person. It is wrong to punish the patient, their family and the hospice that provides the service just because medicare feels that they should die in six months or less. If a patient continues to meet the guidelines then they are eligible for hospice. I think that if medicare is going to give a patient unlimited time on hospice then the hospice should be able to bill and keep the money for which they bill. Hospice provides a terminally ill patient with nursing care, a home health aide, spiritual counseling, a social worker, and different types of therapy, along with providing all medicine that is related to the terminally diagnosis all medical supplies and equipment that the patient needs. The money that is paid to the hospice by medicare is put to good use and is spent wisely. I think by making hospice pay back money that some people will let their patients go at the end of the six months because they dont wont to be penalized and have to pay back large amounts of money, then that leaves the patient out in the cold with no help which is wrong. I hope that medicare will think about what their doing and if they need to cut back spending that they will find another area to do so not one that is so important and needed by so many people.

[jessidawn87]

Myself and all of the empolyees at the hospice i am empolyed at will agree with Bobbie Fleming. It isn''t easy to take away the help you have provided for a patient just because they have lived to long. This is exactly what medicare expects hospices to do. I hope that the decision of congress will benefit hospices so that many hospices, including ourself, will be able to continue to provide the care that our staff gives to our patients.

[serenity394]

We at Serenity Hospice are in agreement with other Hospice Agencies as related to PATH ACT and feels no one should be denied care or hospices denied payment because of a flawed law many years ago that didn,t get revisited.Patients are entitled to end of life care regardless of length of time to one''s eternity which can only truthfully be decided by one and his name is jesus.

[serenity394]

We at Serenity Hospice are in agreement with other Hospice Agencies as related to PATH ACT and feels no one should be denied care or hospices denied payment because of a flawed law many years ago that didn,t get revisited.Patients are entitled to end of life care regardless of length of time to one''s eternity which can only truthfully be decided by one and his name is jesus.

[rememberme51]

Having been a Hospice Nurse for 11 years now, I fully understand the "cost" of the cap which weighs heavily on us all. I am blessed to now work for a company who does the right thing despite the monitary cost. It is unfortunate that many of our patients who are truly appropriate and who meet qualifications to receive Hospice Care have come "discharged" from other Hospices who have kept them as patients long enough to cover cap costs, but then have "dumped" them with few options after they failed to die in 6 months or less. The "cost" of caps is measured in much more than dollars. How demeaning and undignified it is to cause undue worry on families who are already suffering tremendously! I pray that when the time comes for me to need Hospice Services I wont have to worry whether or not I will be cared for after my alloted 6 months are up! The alternative of dying in the hospital at twice the cost to the government in an unfamiliar setting without all of the people I care about around me is less than appealing.

[capt_rich]

Having worked for Mrs. Flemming, I think if they carefully evaluated her current and past patients for meeting the guidelines for hospice, it would become clear why she is having a problem with Medicare Cap.

[gcmc1]

Great show on Hospice! My mother is on Hospice and this story really needs to be told so that Hospice Care in rural areas can survive.

[dbrazeal2]

I own and operate a hospice in Tulsa, OK. I appreciate CBS''s coverage of this very important and daunting situation. It is important, to at the very least inform the public regarding this "cloud" over the end of life benefit which we have all paid for and should expect to be available when we reach the point of medical eligibility...without worrying about "out living" our benefit.
The Senators and Congressmen who sponsored the PATH Bill are to be commended for taking the time and making the effort to understand the end of life needs of their constiuents. Too many time our legislators "land their jobs" and then forget who they represent.
(Continued)

[dbrazeal2]

dbrazeal2 Continued:

Shame on the hospices who aren''t standing up for the rights of those who continue to be eligible for their hospice benefit, yet haven''t died within an acceptable financial timeframe. We should ALL be standing together in this horribly financially devestating time for any single hospice over cap, much less the numbers reported from 2005. Our common sense should tell us that statistics from 2005, are only bound to foretell of future cap problems for many more. So...if you are not discharging eligible patients, and you are billing for every patient you have on service...tell the truth...how long before you have a cap problem?
Let''s all support the PATH bill and let our legislators know that we are united in focusing our efforts on the quality of care for those we serve, and want to stop, thru the Moratorium (PATH) the quarrelling and arguing, which is distracting us as an industry.

[unicorn261]

I think having worked for Mrs.Flemming, Hospice is a wonderful thing for the terminally ill patients who truely need it, but if her patients are carefully evaluated you will see that many of them don''t qualify for hospice. They will let you know that they are there for a free ride. They will tell you that there''s nothing wrong with them they are just on it for the free medication. Now you tell me, is that really hospice appropriate?

[bcanipe]

This is just like all other goverment programs, people will try to "work" the system and this only hurts the people that need the help. Remember a rotten apple spoils the whole basket.

[grammawhamma]

I "used" to work for a Catholic run hospice program. The way they got around this was to start upping the morphine doses before the six months were up. The patients that were allowed to linger longer were those who had substantial wealth and paid their own way.