Martin Huff fell off his bicycle and injured his knee. He spent a few hours in the emergency room in Riverside County and then walked out on his own. He was 67 at the time.
Ten days later, he received hospice care and was diagnosed as terminally ill by a small Covina provider who provided hospice services. He said that he was weak, was losing weight, and could only live 6 months or less.
However, five years after that grim prediction, Huff is still alive. He testified in federal court that no one at the California Hospice Center had given him a medical examination before claiming that he was dying.
"I really never knew what the deal was in a hospice hospital," he said.
An investigation by the Los Angeles Times found that in an industry aimed at providing hospice care, Huff belongs to the majority of older Americans, and their goal is bold and widespread fraud.
Like Huff, many people are recruited by unethical providers without knowing it. They charge medical insurance for hospice services and equipment to provide services to "terminally ill" patients who have not yet died.
The Times found that fierce competition for new patients-each person generates between US$154 and US$1,432 per day in health insurance payments-has spawned an illegal cottage industry, including the cunning of looking for potential patients in nursing homes and other places. Doctors and recruiters offer rebates.
The exponential prosperity of providers has transformed the hospice that was once the realm of charities and religious groups into a multi-billion dollar business led by profit-driven operators.
Nowhere is the growth more explosive than Los Angeles County, and its harmful side effects are more pronounced.
According to the Times’ analysis of federal health care data, the county’s shelters have increased six-fold in the past ten years and now account for more than half of the state’s approximately 1,200 health insurance certification providers.
Extending westward from the San Gabriel Valley, where the California hospice agency is located, through the San Fernando Valley, which is the area with the highest concentration of hospice centers in the country, springing up like mushrooms along a corridor.
"There are too many providers in Los Angeles County, and too many providers are involved for the wrong reasons," said Edo Banach, head of the National Hospice and Palliative Care Organization, the largest U.S. hospice trade organization. ) Say. "People who enter this field for the wrong reasons usually do a bad job."
More important than money.
National inspection records show that some patients who joined hospice care unknowingly later found out that they had signed up for life-saving emergency medical treatment rights. When providers fail to provide the comfort care they desperately need, others endure unbearable pain in the last days.
Others suffer from neglected, festering sores that can grow maggots or lead to hospitalization.
Privacy laws and government reports that keep the names of patients, doctors, and hospice managers confidential have made many cases difficult to quantify and humanize.
However, the Times found that since 2008, the regulatory agencies have listed California as the most serious violations more than anywhere else in the United States, four times as many as in states such as Texas and Georgia. These states also have a large number of providers.
State reports show that despite these citations, California and federal regulators rarely fine, suspend or close defective shelters. During the COVID-19 pandemic, supervision was further weakened as regulators suspended the requirements for most hospice inspections and restricted the types of complaints they can investigate.
California has the lowest barriers to setting up new hospice hospitals, but it is also in violation of the rules in recruiting terminally ill patients without medical certificates.
Analysis by The Times showed that the frequency of patients discharged from shelters in Los Angeles County is 80% higher than that of providers nationwide, which highlights what federal authorities call this rate a red flag for health insurance fraud.
California Hospice Care alleges that Jesse Staten had advanced heart failure while treating him at the end of life. His expected six-month lifespan expired in 2012, but he did not: when the New York Times contacted him eight years later, he was still strong.
"I persevered," said the 75-year-old Staten. "I have a lot of problems in my blood, and I have other problems, but I can't complain."
Federal prosecutors accused the California Hospice Hospital of paying taxpayers $7.5 million in illegal payments related to Staten, Hough, and many other recipients who were not eligible for health insurance. The owner of the hospice hospital and two doctors were sentenced to jail, and several others were convicted or pleaded guilty in the plan.
Prosecutors said that many patients in hospice hospitals are addicts attracted by the promise of free narcotic painkillers.
According to his indictment, some people were recruited by a doctor who collected a bounty per person from the hospice hospital.
One of them is a 47-year-old woman who lost her place on the waiting list for liver transplantation when she signed up for a hospice hospital where treatment was prohibited. It took her several months to recover and she died shortly after finally receiving a new organ.
"This is the last hope. It is incomprehensible to remove that person from the list of liver donors and include him in the plan," U.S. District Judge S. James Otero sentenced a hospice nurse to 18 months in prison. Shi said. "It's ruthless."
As the end-of-life option for terminally ill patients, proper provision of hospice care is a godsend for millions of dying Americans and their families. It provides palliative care and prescription drugs, nursing services, medical equipment, supplies, and spiritual counseling for those with a prognosis of less than six months.
The hospice industry in the United States took root in the mid-1970s, but did not flourish until 1983 when medical insurance began to cover its services. For-profit providers have emerged to meet the growing needs that exceed the capacity of charities and religious institutions that initiate the end of life.
In the past 20 years, the number of providers in the United States has roughly doubled, and health insurance spending on hospice care has increased six-fold to $19.2 billion per year. Today, more than 1.5 million Medicare beneficiaries receive treatment from approximately 5,000 hospice hospitals, nearly a quarter of which are in California.
"Almost all of the growth comes from for-profit providers, which seem to be crowding out local non-profit organizations that have established hospice care models and want to maintain their integrity," said Michael Conners, a long-term care advocate for California Advocates, about nursing home reform.
For-profit operators now account for 70% of all shelters certified by the Centers for Medicare and Medicaid Services, and 91% in California. In Los Angeles County, they accounted for 97%.
According to the satisfaction survey of the National Shelter Report, more than 80% of respondents rated their shelter 9 or 10 points (out of 10), but in Los Angeles County, this number fell to 74%. Respondents in Los Angeles are also unlikely to report that hospice agencies always provide them with the help they need.
Most hospice care is provided in the patient’s home, but services can also be provided in independent facilities, nursing homes, and assisted living centers. Regulatory inspections and financial audits are not frequent, making the system a soft target for scammers.
Sandy Morales (Sandy Morales) is responsible for overseeing the statewide hotline funded by the federal government. Its mission is to help Medicare beneficiaries prevent, detect, and report fraud. He said that complaints about improper operators were filed in 2017. The California Elderly Medical Insurance Patrol Hotline was ignited in the middle of the year, and it has not stopped.
"It's all over Southern California: Riverside County, Hemet, Indio, Long Beach, Los Angeles, Bakersfield," she said. "Now, it is huge."
Morales said that since January 2019, her agency has forwarded more than 100 suspected hospice fraud cases to federal investigators. A doctor’s office in Los Angeles County recently reported that 10 patients appeared to have been fraudulently recruited by a hospice agency.
She said fraudsters follow familiar scripts to induce or deceive health insurance recipients to register for services they don't need. They send recruiters door-to-door to churches, food banks, senior centers, and apartment buildings, often mistaken for hospice care as "extra" health insurance benefits that pay for nursing visits, hospital beds, or other needs.
'This makes no sense. I can't imagine that there are 60 shelters in Burbank that are being treated in the right way. There are not enough people there to accommodate 60 shelters.
Jan Jones, recently retired CEO of California Hospice Network
She said the pandemic has spawned new plans, and unscrupulous recruiters are now using hand sanitizer, gloves and other promises of COVID-19 "freebies" to attract potential customers.
Many registered people don't even realize that they are receiving hospice care.
"They would say,'No, I won't die. I need help with housekeeping and cooking, and that's the purpose of my signing,'" Morales said.
In May 2017, the daughter of an Alzheimer's disease patient told a state investigator that the marketing staff of Paramount's All Seasons Hospice promised her mother to provide 24-hour care. When no one showed up, she called the hospice hospital and was told that the only 24-hour service was provided over the phone.
The hospice administrator admitted to false sales promotion, but most of them dismissed it.
According to a state report that did not disclose the employee’s name, the administrator told the inspectors: “There is a dog biting situation and the competition is very fierce.” “I can’t control what these marketers say or do. They do what they want. Do, and promise to do anything in order to get the patient."
The Center for Medicare and Medicaid Services did not respond to specific questions about the extent of hospice fraud, but said in a statement that the agency is actively seeking to investigate the matter.
"CMS uses cutting-edge data analysis, medical review, and project integrity investigations to identify fraud, waste, and abuse in hospice services," it said. "In the case of potential fraud, CMS will submit these suppliers to law enforcement for further criminal investigations and appropriate administrative actions."
The Office of the Inspector General of the U.S. Department of Health and Human Services reported in July 2018 that improper billing and fraud by hospice service providers cost taxpayers "hundreds of millions of dollars", but the exact extent is unclear.
The regulator declined to comment on the scope of hospice fraud and said it could not provide the number of cases investigated. The Ministry of Justice did not respond to multiple requests for its prosecution number.
But based on interviews with hospice providers and industry experts, as well as reviews of individual cases, state licensing reports, lawsuits, and law enforcement releases of federal data, fraud is widespread.
"Hospice fraud is still rampant in the United States," said Mark Schlein, an attorney at the Baum Hedlund law firm in Los Angeles, who specializes in handling hospice whistleblowers litigation. He links fraud to a large extent with the unfettered growth of the industry.
"This means that the federal health care program pays more money to hospice companies," he said. "When Willie Sutton was asked,'Why are you robbing the bank?' He said,'Because the money is there.'"
The one-mile-long Victory Boulevard is an east-west trunk road in the San Fernando Valley, with more than two dozen shelters. A dilapidated office building in the 13600 block of Van Nuys has 15 suppliers.
“The shelters here grow like mushrooms,” said another tenant, who declined to be named for fear of alienating his neighbors. The monthly rent there is as low as $399, which is very attractive.
Many other people in the neighboring valley communities are part of the huge regional hotbed of for-profit shelters. Many are small businesses, and some are purchased as investments by people with little or no medical care experience.
Federal data shows that since 2010, the number of suppliers in Los Angeles County has soared from 100 to 618.
There are 35 shelters in North Hollywood, 60 in Glendale, 61 in Burbank, and 63 in Van Nuys.
In contrast, New York and Florida have fewer than 50 people.
According to the analysis of The Times, Burbank has a population of 103,000, and the per capita hospice rate is almost 40 times the national average.
"It makes no sense," said Jane Jones, the recently retired CEO of the California Hospice Network, which is a coalition of non-profit organizations. "I can't imagine that there are 60 shelters in Burbank that are being treated in the right way. There are not enough people there to accommodate 60 shelters."
New York, Florida, and dozens of other states require potential hospice owners to obtain a "proof of demand" before obtaining a permit to justify the need for additional providers.
California providers must have no felony convictions, but apart from obtaining state permits and medical insurance certification, there are few other qualifications to open or operate hospice hospitals, and the process only costs thousands of dollars.
"Unlike a hospital or nursing home, there is no high-cost entry point for starting a hospice program," Jones said. "I think a lot of people think this is a simple business, and frankly, I think it's wrong. It's very complicated and complicated, and it's very important to the people we serve."
With the explosive growth, serious care quality problems have emerged.
The Times’ review of more than 800 state permits and inspection reports revealed one case after another in which patients were deprived of comfortable care because of the actions or inactions of hospice providers.
Poorly managed painkillers, neglect of infections, missed care visits, incompetent or dishonest home health assistants-all these are listed as hundreds of violations that require hospice care agencies to develop a plan to correct the problem, but Lead to little or no disciplinary action.
State inspection records showed that patients suffered from lack of painkillers, or maggots crawled out of festering foot ulcers and head wounds. Others either died alone or died without the help they needed, because the hospice hospital did not show up in the last few hours.
"We will never be able to recover from that disaster," Joyce Craig said of the last moments of her 74-year-old brother Peter Craig, an accountant in Los Angeles A partner of the firm, died of cancer in 2017.
The California Department of Public Health licenses and supervises shelters to ensure that they meet state and federal standards, but their ability to punish criminals is limited. The only fine it can impose is a violation of patient confidentiality.
To qualify for hospice care, patients must be certified as terminally ill by their attending doctor (if any) and the hospice doctor. The time for fraud in the authentication process is ripe.
The Times’ analysis of federal data shows that California shelters are the country’s leader in recruiting non-terminal patients for violations, with 57 such deficiencies recorded since 2008, of which nearly three-quarters occurred in Los Angeles County.
The following states are Georgia and Louisiana, each with 22 states. But the actual numbers in California and elsewhere may be much higher because state inspectors encode and classify improper terminal diagnoses differently.
Dying Californians are hurt and neglected by an industry designed to comfort them
An investigation by The Times found that care in the shelter had failed, including improper medication management, neglect of wounds and missed appointments.
At the Eleos Hospice Center in Van Nuys, state officials sampled the records of five patients in December 2016 and found no evidence that anyone had a terminal illness. A permit report stated that the agency "is requesting or attempting to request reimbursement for patients who do not require hospice care and services."
All five people were quickly discharged from the hospital, but records showed that no action was taken against doctors or hospice care. According to a new owner who took over in August, the shelter has changed hands twice since then, and he said he was unaware of these deficiencies.
Inspectors found a similar situation when they checked the records of two patients at the Orion hospice service in Valley Village in November 2018.
The medical director of the hospice hospital re-certified that a patient was terminally ill, wrote that her health and appetite were declining, and her weight was also declining. But this is not what the patient told the state investigator.
"I have no pain and I have a good appetite," she said, "and I didn't lose any weight."
In fact, the records of the host family where the woman lives show that she has gained 7 pounds in the past three months.
When the inspector asked the hospice manager for an explanation, the hospice manager declined to comment. The medical director admitted that he had never weighed the woman, describing a kind of "guess your weight" in a county fair. "The stall method.
According to a state inspection report, the doctor said: "I assess her weight based on my own clinical measurements and judgments, not through any actual recorded measurements."
State inspectors found no records to support terminal diagnosis, and inspection reports did not reflect any disciplinary actions against doctors or hospice agencies, except for the need for a corrective action plan.
For a patient at Sun Valley Guiding Light Hospice Hospital, the evaluation result couldn't be worse.
Women are prone to fatigue; need help with feeding, dressing, bathing, toileting, walking, money handling, and medication; and they can say "less than six understandable words per day," state inspection records point out. She was also incontinent, had a history of falls, was forgetful, disoriented and confused, and was "on the verge of death".
However, in an interview with the state inspector, the woman who was only identified as patient 1 in the state permit report said that her only weakness was back pain caused by arthritis.
The report stated: "Patient 1 said that she knew she was not ready to die, and smiled and denied that her diagnosis was terminally ill, and that her life expectancy was only six months or less."
Despite the evidence to the contrary, the nurses who conducted the terrible, detailed assessment insisted that they were accurate. No disciplinary action was taken, but when the inspector returned 16 months later for follow-up, Guiding Light had closed its office.
Karen Alvarez didn't expect the visitors from Ace of Hearts Hospice at first. They showed up in the Sierra Retirement Village in Lancaster with a lot of fast food. After all, the apartment manager said that many of her low-income tenants appreciate free meals.
But Alvarez was quickly shocked by the aggressive strategy of the Ace of Hearts. They took over the lobby every Wednesday, dragged residents back to their units, and sold them “free” hospice care, hospital beds and electric scooters, all These are all charged to taxpayers.
"You know, hospice people are very gentle and talk to you very well. They are understanding and kind," she said. "They don't swarm like these people."
Few shelters better reflect the most serious problems plaguing the industry than the Ace of Hearts — or emphasize the failure of regulators to solve these problems.
According to a felony criminal lawsuit and a state report detailing a series of deficiencies, more than a dozen patients were not terminally ill and should not be included.
Federal records show that this hospice hospital is located in a small office on Turonga Foothills Boulevard. From 2014 to 2016, there were at least 115 violations, ranking second among California's 1,200 suppliers in the past decade.
The nearly 200-page state inspection report records detailed information about violations, including mishandling of medications, neglected sores, and multiple misses by nurses and home health assistants.
In the case of one patient, the assistant did not show up 18 times in a few months.
"This must be a computer malfunction," the Ace of Hearts administrator explained to the state inspector, who discovered that dozens of other patients had missed their consultations.
Rozanna Avetyan, the owner of Ace of Hearts, 42 years old, signed the inspection report as the administrator. She did not respond to the interview request. The interview request was left to a person from Stevenson Ranch and a person who answered the phone but did not want to be identified. woman.
Her lawyer Donald Marks did not respond to repeated phone calls and email messages.
If you or your loved one needs hospice care, what do you need to know
For families, choosing a reputable hospice hospital can be a challenging task during emotional moments.
Medical insurance data shows that in 2016, the government paid approximately $450,000 for 29 patients, and nearly two-thirds of them were discharged alive. Although hospice patients may be recertified for more than six months of care, federal officials say that very long hospital stays and high “real-time discharge” rates are potential indicators of fraud.
According to the analysis of medical insurance data by The Times, the 62% real-time discharge rate of Ace of Hearts in 2016 was almost six times the national level that year.
In October of that year, state inspectors failed to find that 3 of the 11 patients sampled were terminally ill. State inspection records show that some people have been accepted by the hospice medical director, who signed the certificate electronically.
The unidentified doctor's office is located in Palm Springs, more than 100 miles from Tujunga. He told state officials that he had not recalled some patients and did not know how his signature appeared on their certificate.
According to a state permit report, he said: "I don't like computers, so I don't use them." "I didn't sign anything electronically."
Incorrect certification can have serious consequences: the report states that some registered non-terminal patients were shocked to discover that they had lost their existing medical insurance in the process.
At least two people lost HMO insurance when participating in hospice care without being told they could refuse. State permit records show that one of them is registered in assisted living facilities and the other is registered in host families.
"HMO wouldn't even see him in the emergency room, he didn't understand," according to a state report, the board of directors and the head of care told state investigators.
The report said that when asked for an explanation, the Ace of Hearts administrator accused the host family's boss of referring the man, who suffered from severe bedsores during hospice care.
The administrator said: "I only had trouble with the board and the care owner." "The patient now has multiple wounds. I told [his] caregivers that we are not making wounds here."
The most obvious example of the worst wound care is a patient treated by an Ace of Hearts nurse who did not have enough clean gauze to cover a severe foot ulcer.
"She picked up the dirty and discarded Kerlix dressing from the wound. The wound was covered with some old red secretions. She reused the old dressing on the clean dressing," one person witnessed the process. Wrote the state inspector. Violation of infection control protocol.
This is just one of a long list of serious flaws over the years.
“The cumulative effect of these systemic practices has caused hospice care agencies to fail to ensure that they provide quality medical services in a safe environment,” said a 2016 inspection report.
However, despite this discovery, Ace of Hearts continued to operate for three years. It was not the state regulators that was eventually cancelled, but its own weekly free breakfast sales promotional visits to Sierra Retirement Village and the nearby Aurora Village Retirement Center.
Sierra’s comprehensive facilities manager, Alvarez, told The Times that two federal agents came one day to ask her about Avetyan’s visits and rebate offers, up to a maximum of $300 per patient. Avetyan also owns Team Hospice in Lancaster.
"I'm not interested at all," Alvarez, who has not been accused of wrongdoing, said of the kickback. "I said,'No, I have a job, I don't need that.'"
Alvarez said a county social worker disclosed the news to the authorities, and she was surprised to find that a resident she visited was given a "hospice bed" when she was not sick.
In 2018, the California Attorney General's Office filed fraud charges against Avetyan and four others, claiming that her shelter charged Medicare and Medi-Cal for unqualified patients of $1.2 million.
The prosecutor stated in the criminal proceedings that Avetyan paid more than $180,000 in kickbacks for illegal referrals, some of which were provided by a woman who worked in a doctor’s office and collected names from patient lists.
The complaint alleges that another doctor, Dr. Blanca Galapon, who is 80 years old, was accused of falsely proving that a dozen patients were terminally ill in exchange for payments that Avetyan did not specify.
Avetyan pleaded guilty to one count of conspiracy to pay and accept insurance rebates in April 2019 and was sentenced to six months and four years probation.
Galapon and the other defendants reached an agreement to postpone the prosecution or probation.
In January of this year, Avetyan was banned from participating in all federal health care programs including Medicare and Medicaid for at least five years. By earlier this spring, the Ace of Hearts and the hospice team had closed their offices.
But court documents and other public records indicate that Avetyan seeks to continue to participate in the hospice industry.
The Times found that at least five shelters located in an office building in Van Nuys appear to have been spun off directly from the Ace of Hearts, or have important links with it. An online biography that lists two young women as chief executives of five hospice hospitals describes them as former ace employees.
Without your support, such a story would not happen.
One of them, Arpine Melikyan, is a 2019 graduate of California State University, Los Angeles. He was once the Ace of Hearts accountant and now leads two other providers, Life Hospice and High Care Hospice.
In a lawsuit in 2019, Avetyan claimed that she agreed to pay Melikyan US$5,000 a month and provide personnel and other resources in exchange for 30% of the shares in the two shelters. Melikyan declined to comment on the lawsuit, which accused her of breaching the transaction.
Avetyan will return to court on December 16 and is charged with violation of probation.
The prosecutor declined to provide details, but stated in an email to The Times that she continued to charge Medi-Cal for hospice services after being barred from participating in the program.
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Kim Christensen is a Pulitzer Prize-winning investigative journalist and joined the Los Angeles Times in 2005.
Ben Poston is an investigative reporter specializing in data for the Los Angeles Times.
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