A Texas Hospice Provider’s Deadly Scheme, Part 2

[00:00:01] Bob: This week on The Perfect Scam.

[00:00:03] This case boils down to one, the greed and control of Brad Harris and kind of everything that goes along with him, but also the abdication, the failure of the doctors to practice medicine, to be true to their license, and to take oversight and care of their own patients. They essentially outsourced it to Brad Harris with horrible, horrible consequences.

(MUSIC SEGUE)

[00:00:30] Bob: Welcome back to The Perfect Scam. I'm your host, Bob Sullivan. When we left our story last episode, FBI investigator Tom Cook was looking into allegations that a hospice company was mistreating patients, was falsifying medical records, and in some cases, the CEO, Bradley Harris, was ordering medical professionals to take steps so patients died more quickly so the company could make more money.

[00:00:56] Tom Cook: Well, it was, it was all kind of a whirlwind, what we're talking about at the end of life for patients. You know, hospice patients at the end of life is typically in a lot of pain, and hospice, what we see very often is that those patients are prescribed really powerful narcotics, typically morphine, um, for shortness of breath, sometimes Dilaudid as well as other pain medications. But when we showed the records to outside medical experts, I mean they were horrified at the, the amount, the speed, and the volume of medication. Morphine is, is a very good drug when used appropriately, but when stacked hour after hour at very high doses, it becomes toxic.

[00:01:37] Bob: Investigators were so horrified that they turned what could have been a typical Medicare fraud investigation into an urgent case, a matter of life and death.

[00:01:46] Tom Cook: The FBI along with our other law enforcement partners, we, we kind of work cases in, in two realms, and you have the typical healthcare fraud case, which is about the dollars, and then there are cases about patient harm. With those patient harm concerns, we, we kick into a different gear.

[00:02:07] Bob: A lot of the urgency is driven by evidence that Tom had seen on the CEO's cellphone. As I mentioned last episode, Bradley Harris was a compulsive texter, sometimes sending up to 2,000 messages to workers every day. And some of the texts are horrific. According to NBC News, he once told a staff member, "You need to make this patient go bye-bye." According to the Dallas Morning News, another time he wrote to an employee that, "If she would just give her one mil of Ativan and turn her, she would die." Later, when the patient did die, Harris followed up with the nurse writing, "Nice work."

[00:02:48] Tom Cook: Those are just horrifying messages to read. But we also saw instances in which you know I, I think quite frankly he just I, it's hard to explain. He got frustrated or he, he just wanted something done. And he would tell his nurses that they would push the max dose and they're, they're horrible things to have read.

[00:03:08] Bob: So the FBI takes action almost immediately. That's not their style. It can often lead to destruction of evidence, but there's no time to waste in this case.

[00:03:18] Tom Cook: I will tell you that I've worked many healthcare cases since then, and I always describe this case as being worked backwards.

[00:03:25] Bob: Working the case backwards. So first, they get the patients out of immediate harm.

[00:03:31] Tom Cook: In this case, in, in Novus, we had no bank records, we had not gotten kind of an official copy of the medical records for the company and, and we really didn't have what we would normally have in, in another case, but given the patient harm concerns, given the need to act and to find out what was really going on, we needed to make a big step and quickly. And so we, as a case team, decided the search warrant was the most, the most appropriate course of action, so that's what we did in mid-September. Based on what we found at the company, shortly thereafter we, through HHS primarily, recommended that Medicare suspend payment to this company, essentially putting them out of operations so that their patients would no longer be in harm's way.

[00:04:15] Bob: That sounds like a really big step too. I mean is that, what happens to the patients in a situation like that?

[00:04:21] Tom Cook: So all, all Medicare companies have a need to have backup agencies and plans so that their patients can get transferred to an appropriate agency, and they're, in North Texas, there's a, there were a lot of hospice companies.

[00:04:34] Bob: With all the disruption, there's no way to keep the Novus situation out of the news. So investigators soon have to explain to all the families involved what's going on. In some cases that means telling families that a loved one might have died sooner than necessary because Novus was worried about revenue.

[00:04:55] Tom Cook: We did a number of interviews with some patients, many more family members, um, yeah they're, they're hard conversations to have.

[00:05:05] Bob: I mean I can't imagine sitting there thinking that maybe my dad or my mom you know died too soon because this guy was lining his pockets or, or went through um, you know was, was heavily medicated when it was unnecessary. That just seems awful.

[00:05:20] Tom Cook: Uh, it's hard to describe.

[00:05:23] Bob: One of the family members the FBI talked with is Judy Venable-Grogan. You met her in Part 1 of this story. Remember, after her mom almost died several times in Novus' care, she hired a different hospice provider. And when she couldn't get the experience out of her mind, she wrote a complaint letter to Medicare which turned out to be essential to the FBI case. First, state investigators reach out to her.

[00:05:48] Judy Venable-Grogan: Yeah, and that organization contacted me letting me that they had received the letter and they had some concerns, and they talked with me. After that conversation I didn't hear anything again for months until the investigator with the FBI contacted me. Now that'll wake you up. Now they were taking it seriously and I could tell they were going to do an investigation. It was not though until I spoke to the gentleman with the FBI and googled Novus Hospice that I learned it was as deep and sick as it was.

[00:06:21] Bob: Judy had kept a spreadsheet of treatments from others received and plenty of other documentation. Novus had told her that was overkill. The FBI had a different view.

[00:06:33] Judy Venable-Grogan: I shared with them that you know that I had the sign-in book that Novus was to use, 'cause they were wanting to know how I knew no doctor had ever been out there, and I said, "Well I have the sign-in book." And I can prove that one because they said, "Whoever comes in is supposed to sign the book. If they don't sign the book they're not there." And I said, "I kept the book." He said, "Do you still have the book?" I said, "Yes." Which, I think, again was one of the pieces of evidence that was important in proving, you know, the guilt. And then I told them about the Excel spreadsheet. And I, I mean we became a team. They wanted to know how quickly I could get the information to them.

[00:07:15] Bob: The spreadsheet, the book, they're important because as prosecutors build their case against the Novus defendants, they have to prove the company was misrepresenting the amount of doctor visits that patients received.

[00:07:27] Tom Cook: So Medicare has a requirement that after six months, or two episodes of care to be more precise, that a doctor will visit a patient. In this case that was important because the doctors, the key doctors, Dr. Mark Gibbs, Dr. Laila Hirjee, were forging those visits. They were handwriting doctor visits. They had visited patients and certifying they were still terminally ill when they in fact had not done the visits. And this was done in coordination with Brad and some of the other office managers at the company.

[00:07:57] Bob: The misrepresentations are dramatic. Hospice patients require regular recertifications signed by doctors to confirm they are, in fact, terminally ill. Well, at Novus, many of these recertifications were fake.

[00:08:13] Tom Cook: One of the allegations was that Dr. Gibbs had visited, I believe it was 16 or 17 patients, and was at the Novus office by 11 a.m. for his meeting. First of all, there's no way you can do 16 visits in a two, three hour time period in the morning. And the geography of North Texas is such that patients were 60 miles away from each other. Now that's a circumstantial case. It's something that we had to deal with is proving a negative is very difficult. It's hard to say that a certain person didn't do something on a certain day. But through all the records we collected, we were able to prove some of those allegations, and then, you know in, in another example of this for Dr. Hirjee, we had an example where she was actually on vacation, I believe in Cabo, and she and Brad were texting after the fact, and he needed some recertifications done. So he sent her text messages about the specific facilities, assisted living facilities she had visited and the times and the dates that they, she had been there, and then he would have his office staff send her a summary from one of his nurses and she would do, you know, the crib sheet version in handwritten notes and sign it and send it back to him, and he'd, he'd put it in the patient's medical record. So those were some of the examples of, you know, when I talk about they were making up these visits, they were fraudulent visits, they were fraudulent certifications.

[00:09:28] Bob: As Tom builds his case, it's clear that it wasn't just Bradley Harris who was in on the crimes. There are many more responsible parties inside Novus.

[00:09:39] Tom Cook: Look in any, in any criminal conspiracy, there's, there's a, a leader. And, and there's a lot of focus paid toward the leader. But there were a lot of other folks who were involved. There were also a number of nurses. They knew through their medical training what was right and wrong, and, and how, who to take direction from. And they didn't. And some of the, you know, Brad Harris wasn't bedside with patients, the nurses were. So they're responsible for the actions that they took at those, at those patients' bedsides.

[00:10:06] Bob: And a lot of people were making money for doing the wrong thing.

[00:10:11] Tom Cook: Something we haven't talked about was the absurdly high salaries they were paying to some of their doctors; Dr. Gibbs and Dr. Hirjee in particular, were getting salaries way outside of kind of the normal market rate.

[00:10:23] Bob: Do you know how much they were making?

[00:10:24] Tom Cook: Dr. Hirjee went from essentially zero, and every two to three months her salary essentially doubled until she was making $12,000 a month for what is supposed to be 40 hours of work in a month, although from the records that we see, there is no way she was putting in nearly that amount of time. In addition, they were getting paid $150 for each of those recertifications that they were faking.

[00:10:51] Bob: Novus even went so far as to pay outside companies for help in recruiting new hospice patients. And, they recruited people who didn't even need hospice care.

[00:11:03] Tom Cook: We saw fraud throughout, throughout this company, every, every phase of hospice. So we saw fraud in the recruitment phase. They were, they would go out to facilities and essentially bribe them to send patients to their hospice. And so the, these assisted-living facilities looking for, you know, a little extra handout or a little extra help, the facility would send patients that may not have been hospice appropriate, and Novus would certify them because Brad had the doctors in his pockets. They also would mine patient records from other companies' electronic medical records. They got log-in information through a third party company, trolled for patients who were elderly, and then, according to some of the allegations, Brad Harris' wife, Amy, would call the patients under false pretenses saying she was from their insurance company, or they had a, they had a new benefit from the, that she was from the doctor's office, and they would send, they would send out a nurse to recruit these patients into hospice. This part of the scheme, this false recruitment is what brought on a lot of non-terminally ill hospice patients that brought that number up.

[00:12:11] Bob: And that included, and this is just so hard to believe, they'd sign up patients without ever mentioning they were being placed into hospice care.

[00:12:22] Tom Cook: I'll give you an example of a patient. She was, she was with a third party company. They accessed her medical records through their log-in multiple times. They contacted her, they signed her up. We had emails from the company where staff was saying, "If you visit this patient, don't mention the word 'hospice. Provide her the service, but don't, don't tell her that she's on hospice." She shortly thereafter figured out kind of that the gig was up, and was discharged from the hospice service. I think she'd spent maybe two, two or three months on, on service with Novus. This occurred in 2014. In the spring of 2021, she was still alive. She'd never had a terminal illness. They had never talked to her primary care doctor, or any doctor associated with her care. What they had done is had their own doctors falsify a certification that she was terminally ill, or in, in some instances, Brad or others would write the certification and sign as if they were the doctor.

[00:13:27] Bob: It takes two years, but when the investigation is complete, more than a dozen Novus employees are indicted. In addition to CEO Bradley Harris and Drs. Hirjee and Gibbs, there is one more doctor, four nurses, and several administrators who are charged with various fraud felonies. In a press release, US Attorney John Parker says, "That these defendants used human life at its most vulnerable stage as the grist for this scheme. It displays a shocking level of depravity."

[00:13:58] Tom Cook: So really this, this, this case boils down to one, the greed and, and control of Brad Harris and kind of everything that goes along with him, but also the abdication, the lack, the, just the, the failure of the doctors to practice medicine, to, to be true to their license, and to take oversight and care of their own patients. They, they essentially outsourced it to Brad Harris with horrible, horrible consequences.

[00:14:22] Bob: Tom finally meets Bradley Harris when he's taken into custody.

[00:14:26] Tom Cook: Yeah, so I, I was there when we arrested him in, in 2017, and we had debriefed him.

[00:14:33] Bob: Do you have any im--, impressions about the first time that you saw him, the first time you talked to him?

[00:14:36] Tom Cook: It, it's a very, it's a very complicated story. Um... he, he's a, a very sick person.

[00:14:44] Bob: Four more years go by, but on the eve of his criminal trial in early 2021, Harris agrees to plead guilty and to testify against two doctors who take their case to a jury. Their trial gives Judy a chance to tell her story to the world. It's been nearly 5 years since the initial indictments, and even longer since Judy's mom was mistreated at Novus, but Judy wouldn't miss her chance to testify. And under intense cross examination, she stands her ground.

[00:15:15] Judy Venable-Grogan: I think I was there a total of 7 or 8 days before I was able to testify. And it's quite surreal, you know. They kept trying to, to pressure me to say that a doctor could have been there. And I finally said, "Yes, a doctor could have been there when I wasn't there." But I would have known that a doctor came because anyone that cared for mother was hired by me and their instructions were to let me know of anyone that came in, you know.

[00:15:47] Bob: As it turns out, Judy's careful recordkeeping is crucial to making sure justice is served.

[00:15:54] Judy Venable-Grogan: Unbeknownst to me, that Excel spreadsheet was the critical part of the investigation. And I think they were uncomfortable with me doing that because I was, in fact, documenting against them, not knowing that's what I was doing, but it made them uncomfortable.

[00:16:11] Bob: A jury finds Judy and all the other evidence persuasive, and in May 2021, both Gibbs and Hirjee are convicted of conspiracy to commit healthcare fraud and other charges. A total of 13 individuals indicted for crimes at Novus are convicted; Gibbs is sentenced to 156 months in prison, Hirjee, 120 months, and Harris, 159 months. In all, the 13 employees are sentenced to 84 years in prison for their crimes which include stealing 27 million dollars from Medicare. But it isn't about the money for people like Judy. It's about the inhumane way their loved ones were treated. You might remember from episode one, that Judy's mom had trouble even seeing a doctor at Novus. When Mom needed help, all she ever saw were faxes sent by a doctor, Dr. Fax, they called him.

[00:17:06] Judy Venable-Grogan: And I didn't know it at the time, but one of the doctors that was being tried in that hearing was actually supposedly Mother's doctor that we referred to as Dr. Fax.

[00:17:18] Bob: So when Dr. Fax is sentenced to many years in jail, how did that feel?

[00:17:24] Judy Venable-Grogan: I was relieved that it was over number one, and I was glad they were found guilty. I wished it had been longer. But it wasn't, but they, they won't have any money when they get through and out. But it was, it was a relief.

[00:17:37] Bob: Tom is relieved too that all the defendants are found guilty, but of course that provides only so much comfort to the families involved.

[00:17:46] Tom Cook: This case, the prosecution, the sentencings is really a very small, a small piece of closure, a small piece of justice for the patients and their families. We did everything that we could do given kind of the, the challenges of working a hospice case, and the challenges of working this case in particular. So I'm, I'm proud of the work that we, that we did, that the team did, and that our prosecutors did in getting this done and even though it took a long, long time.

[00:18:13] Bob: A long, long time. The initial search warrant was served in 2015, and the sentences were handed down in 2022. But, justice was served.

[00:18:25] Tom Cook: It really took a year's worth of investigating, of kind of cracking into the, the center, the core of the company, getting through the facades on the outside to figure out the true nature of what was really going on. And that, that was very difficult to do. But once we got into that core, once we knew who was talking to who and we'd seen the audit trails and we reviewed the bank records, I think the truth can, the truth was able to come out. Now I will say that there were, you know people like to talk about good people and bad people, but there were folks who definitely got caught up in the scheme, got caught up in the culture who absent some of these really negative influences, probably wouldn't have committed federal crime. But, you know, we, we have to balance what they did with the justice for the victims. You know and, and people are always very contrite after they're caught, but that doesn't undo the damage that they'd done to the community and you know, quite frankly, at the end of the day, this is still a healthcare fraud investigation. The taxpayers are on the hook for about $60 million in billings by Novus. So this was a large financial fraud as well.

[00:19:38] Bob: Judy's mom didn't live to see the convictions, but once she was given the care she needed, she showed immediate improvement and well what happened next turned out to be a very special time for the two of them.

[00:19:51] Judy Venable-Grogan: Within 24 hours of after getting Mother on the correct antibiotic, she started coming out of this pain that she had. And as the Methadone began to help her come off of the addiction to the medications, she became my mother again.

[00:20:11] Bob: Wow.

[00:20:12] Judy Venable-Grogan: And the last six months of her life, we were able to have a really normal, healthy relationship. There would be periods of time where she would have some of the dementia, but there would be more, I would say it got to the point that it was more 80% of being a normal patient, aware of the fact that they're bedridden and that they're sick, and that they're dying.

[00:20:48] Bob: That's, that’s fabulous. I'm, I'm, what a, what a, what a gift to have that. Oh my God.

[00:20:53] Judy Venable-Grogan: Right.

[00:20:54] Bob: Judy got her mom out of Novus and got her mom back. They were able to care for each other during this very, very important time in life, and made the most of it.

[00:21:07] Bob: What an amazing gift that you were able to have a, a pretty normal relationship with your mom after that. Did you ever talk to her about any of this?

[00:21:14] Judy Venable-Grogan: Any of that? No, because see, you've got to remember at that point I didn't know it was this bad until later. There is a really funny story, I don't know that you'd even want to hear it, but...

[00:21:28] Bob: Oh, I do.

[00:21:29] Judy Venable-Grogan: Now, you've got to go back to the fact that my mother worked in ready-to-wear, right? And Mother was, had written her obit in several different times and we would find it when we'd go through the paperwork, but she also had two or three dresses picked out she wanted to be buried in. And so when it became obvious that we were going to have to find her something to wear, Mother had lost a dramatic amount of weight. Well my sister and I started trying to find a dress, and so we finally did. And to make a long story really short, when she started feeling better we, I started talking to her about her funeral and what she would want, and she was well enough about it. I said, "Would you like to see the dress that Joyce and I picked out?" And she said, "Yes," which brought me relief because I didn't want her to be buried in something she didn't like. So I brought it out. Now we found this dress, although we shopped everywhere, Bob. At Neiman's, there was not a shop we didn't try. We went to an estate sale, and it was in a barn out in the middle of nowhere that we find this dress in this plastic bag. It was perfect, a gorgeous dress. So we bought it. I think we paid $2 for it. Had it cleaned. Gorgeous. Showed it to Mother, because I'm concerned she wouldn't like it, and I said, "Mom, you've lost weight, and this dress is much smaller than you're used to, but I think you're probably a 12 or 14 now." And I showed it to her, oh and loved it. She actually loved it. Then we picked out all the jewelry she was going to wear. Now this was mid-morning. That afternoon about 2 o'clock, she said, "Judy." I said, "Yes." She said, "I think you need to take the dress back and get me a 12." (laugh) I go, "I don't think they have it anymore, Mother."

(chuckles)

[00:23:30] Bob: Well you want it to fit right, don't you?

[00:23:31] Judy Venable-Grogan: Exactly.

(chuckles)

[00:23:35] Judy Venable-Grogan: I said, "I'm sure we can make it do," because I'm thinking, how am I going to explain to her that I found this dress in a barn?

(laughter)

[00:23:44] Judy Venable-Grogan: She had, somehow or another had got a bunch of Neiman Marcus labels, and she would stitch those Neiman Marcus labels in dresses that she made us along the way, or she had put them on her outfits for her dolls. So my sister had saved one of the Neiman Marcus labels... that dress, has a Neiman Marcus label in it.

[00:24:08] Bob: Oh my God. That's great.

[00:24:12] Judy Venable-Grogan: So we did have fun.

[00:24:14] Bob: Judy's story, all the stories from Novus are really important because hospice can be such a gift, such a crucial time for everyone involved, but when terminally ill people are treated like dollar signs, the system is badly broken. And it's important, people like Judy and Tom step forward and work to fix it. The depravity in the case still haunts Tom.

[00:24:38] Tom Cook: It's a very hard thing, even for me, to think about. My, my hope is that this case is unique. I know for certain it's not indicative of the hospice industry whatsoever. Because it's just, you know, it almost doesn't seem real sometimes. But what I, what I would say for, you know, folks in this situation, a lot of this fraud took place and was successful because of the trust people place in, in the Medicare system, and in medical professionals. And with good reason, because they have the training and the experience to know how to, how to handle a very complicated set of diseases, usually. But if it doesn't feel right, my recommendation is to trust your gut and to get a second opinion, to switch providers, to do your own investigative, you know, your own independent research, to know your rights. For example, there were, you know, many patients, and really their families that would say we wanted to see the doctor, and the doctor never came. Well, in hospice, at a certain point you have a right to see the doctor. The doctor is required to see you. And if those things that are supposed to happen, that are mandated to happen aren't happening, it's time to switch providers and to get a second opinion.

[00:26:04] Bob: Judy's story could have ended much, much worse, but she was willing to act on her gut instincts and switch hospice providers which made all the difference.

[00:26:16] Bob: How simple or difficult is it to change companies?

[00:26:19] Judy Venable-Grogan: It's really not that difficult. Uh, you just have the interview with the one that you want and are transferred over, and they act-- the new hospice company will contact the other company and they'll transfer, in our case, all of the equipment. We didn't have to change beds. The only thing that's changed is the caregivers. And all of the time that Mother had been with Novus, I kept asking for a doctor to come see Mother. And that was one of the key points of my testimony at the court was that no doctor ever did come in. As soon as we transferred to the new hospice company, a doctor was out within the first three to five days. So if someone's listening to this, who has a patient with hospice and a doctor's been through the door, I have since learned that that's a pretty much a requirement that a doctor actually see the patient.

[00:27:19] Bob: Judy still struggles with everything that happened, still struggles to even talk about it. And we are really lucky she decided to talk with us.

[00:27:28] Judy Venable-Grogan: The owner of the company supposedly was ordering this one particular, maybe two nurses, to kill patients. It was, "Make them go bye-bye."

[00:27:39] Bob: I can't, in my wildest dreams, imagine what, what it was like for you to actually see that.

[00:27:48] Judy Venable-Grogan: Hmm. Um, well to talk about it, Bob, I mean I've tried my best to put this behind me. And in all those months between each writing a letter and letters passing and everything, it was a nightmare. And then to find it was such a nightmare on top of what you thought it was. You have to put it behind you so that you can mourn the loss of your parent. But every time I was contacted with the FBI, it all had to come back. And my prayer before this call ... was that I could talk about it one more time. And that it would go away, and I could, you know, I could keep something like this happening.

[00:28:42] Bob: I don't know if I have that power, but I hope I can help a little bit. But it's going to do so much good that you're having this conversation with me.

[00:28:50] Judy Venable-Grogan: I hope so. That's my prayer, that's my hope. That if there's just one person out there, that can't understand why they're getting so much pushback from a medical doctor or a medical facility, not to think they are the problem. But to investigate it. There are agencies that they can reach out to. There are things that they can do to get their care, their, their loved one the care they need. And it's not them, they're not the problem. If you feel there's something not right, trust your gut. Don't let anyone make you think that you're crazy or that you're overprotective, or that you're not wanting your loved one to leave. Of course you don't want your loved one to leave. But you want your loved one to be comfortable, and to receive the care that best, it's palliative care with hospice. It doesn't mean you don't get any care. Palliative care means that your loved one is not hurting. If they're hurting, question it. That's what I would want them to know.

[00:30:15] Bob: That's just a really, really clear helpful statement: If they're hurting, question it.

[00:30:20] Bob: And, thanks to Judy's questions, Novus didn't get away with it.

[00:30:25] Judy Venable-Grogan: I mean there's, there were so many things uh, that went on. But in reference to The Perfect Scam, um, that was, they thought, The Perfect Scam. But uh, luckily there's no such thing. Someone that, you know, the truth always comes out. If not in the wash, in the rinse.

[00:30:51] Bob: It's really important to say that most people who work in hospice care are doing a very hard job under very difficult circumstances. And it can really be a beautiful, emotional time, full of love and acceptance for everyone involved. You might have heard that former President Jimmy Carter just entered hospice care just as we started to record this episode. But it's important to understand how hospice is supposed to work and how you can get the right care for you and your family. So we invited Dr. Charlene Harrington, to speak with us. Charlene is both a nurse and an academic who has studied elder care for decades.

[00:31:30] Dr. Charlene Harrington: I think hospice is a very important service in terms of make--, making people comfortable at the end of their lives. And that can be very helpful to the family because it's a distressing time for the family and so it's one of the most valuable services. And I personally have experienced using hospice in my own family. So I know that it can be really, tremendously useful.

[00:32:03] Bob: And, you know, I also think the nurses and doctors and other healthcare professionals who work in hospice are generally heroic.

[00:32:11] Dr. Charlene Harrington: Yes, I, I think they, many of them feel that it's a calling, and they're very dedicated to helping people at the end of life. And they have unusual skills that many other health professionals don't have. Just in being able to help people express their own feelings and keeping calm, and knowing how to handle difficult situations. And they're very good at communications.

[00:32:42] Bob: And it's a lot more than just taking care of uh, medications, right. There's a lot of emotions and, and fear.

[00:32:48] Dr. Charlene Harrington: Yes, it's, it's emotional work, and very difficult, and it can be stressful for the providers that are giving the care themselves, so they sometimes have to take their own breaks from it.

[00:33:04] Bob: Hospice has changed a lot since the US government decided to pay for hospice care through Medicare and Medicaid in the 1980s.

[00:33:13] Dr. Charlene Harrington: It was nonprofits and many visiting nurses associations that offered the service. And so it was truly a calling for people that worked in that area. And then later on, the government allowed for-profit hospice to come into business, and we saw considerable change in the way hospices were organized and operated after that.

[00:33:42] Bob: Today roughly two-thirds of hospice care is provided by for-profit companies.

[00:33:48] Bob: It, it seems uh inevitable that if you are, you know, driven by profits, that you're going to do everything you can to be, you know, quote-unquote more efficient, and that's going to me fewer visits from doctors, fewer nurses per patients, right. Is that what we're seeing?

[00:34:04] Dr. Charlene Harrington: Yes, that's, that's correct, and that's what makes a situation very difficult. Some of the hospices try to avoid having a physician visit because that's going to be costly. And they limit the number of RN visits, and of course, the RN visits are the most important because they do the assessment and the whole plan for the patient's care. And then they also may cut back on the nursing assistance which some hospices can provide maybe three times a week, and other hospices try not to provide it at all.

[00:34:47] Bob: Part of the problem for families new to hospice is they might not know what they're entitled to.

[00:34:53] Dr. Charlene Harrington: There are, are different kinds, kinds of care; there's short-term intensive type of hospice care where when someone has a very short time that they're expected to live, and the longer term care that the hospices only provide a limited amount of services. Often the family is expected to hire their own assistants or provide the care directly themselves. And the hospice mostly oversees the care that's provided. So there's a huge variation in the amount of services that hospices offer.

[00:35:34] Bob: I asked Charlene to give me an example of what one hospice experience might look like.

[00:35:40] Dr. Charlene Harrington: Well ideally you would have a registered nurse visiting every week. You would have one that came out and did the assessments, and then they would be checking to see how the care is going. And sometimes the hospices substitute licensed vocational nurses for the registered nurses. And this may be appropriate in situations where the patient is expected to live for a longer time period, but in other cases, it's definitely not appropriate. It's better to have the registered nurse because they have higher training. And I would think they should expect to have a nursing assistant provide bathing and help with care for maybe three hours, at least three times a week, and they would ex--, expect to have the social worker come at least, maybe once a week. And then they should be able to call if they wanted a physician to come out. They should be able to ask for that anytime. And they should be available on the phone so that the caregivers and family could call and ask questions or get help in an emergency situation.

[00:37:05] Bob: I told Charlene that Judy complained that her first two hospice providers promised a lot during the recruiting phase, but then a few months after they started care, the level of attention started fading. And I asked, is that typical?

[00:37:20] Dr. Charlene Harrington: Yes, I think that's common. So that's why you need to think about what type of hospice you should select to begin with. And I could mention some specific things that I would look for, for my family.

[00:37:35] Bob: Yes, please.

[00:37:37] Dr. Charlene Harrington: Okay, well first of all, I would look for a nonprofit hospice. The for-profit hospices have less services and poorer quality of care. And I would avoid a hospice that's part of a chain. In other words, a big company that has hospices around the state or the country, because those companies have the worst reputations. So ideally you would look for one that is locally owned, and has a good reputation that's a nonprofit hospice.

[00:38:18] Bob: That all makes good sense to me. Are there similar things that maybe families can look out for if they're in hospice now and they have a sense things aren't going quite right? So, so like give me an example of a sign that something is wrong.

[00:38:33] Dr. Charlene Harrington: Well if you can't get, you can't get anybody on the phone, and if you can't talk to the registered nurse and ask questions or let them know what's happening. Or if you are unable to get a hold of a, of the physician, the physician should also be responsive to questions from the family or come out and assess the situation. So those, those would be the first signals of, of a problem.

[00:39:04] Bob: And there are systemic problems in hospice care right now, Charlene said. For one, some complaints about providers are never examined because investigators are just stretched too thin.

[00:39:15] Dr. Charlene Harrington: Unfortunately, the Medicare oversight is very poor. The state has a licensing and certification program that is supposed to be under contract to Medicare to assess hospices on a regular basis. But unfortunately they, for various reasons, are not doing that. So a hospice may not even be assessed every, more than every three years. And sometimes less frequently than that. So that's a big problem because the, the oversight is not there. And also when families file complaints, the state is supposed to investigate, but they often don't have enough staff to do that.

[00:40:02] Bob: And also, the way Medicare compensates caregivers creates fat incentives. Incentives to seek out certain kinds of patients and neglect others. That's what ultimately drove the choices that Novus CEO Bradley Harris made.

[00:40:16] Dr. Charlene Harrington: Well I, I think hospices sometimes are looking for patients that are not very sick. And so that they will stay, can stay in hospice for a longer time period. And that patients that they don't have to provide much care to. And so that's definitely a problem. In other cases, the hospice, they are overmedicating patients and hastening in the death of patients. So you, you have these, the two, two-sided situations partly because of the payment, and Medicare seems to be more concerned about the payments than they are about the making sure the services are appropriate.

[00:41:05] Bob: So there's certain, specific kind of patients that are the most profitable ones, the ones that aren't very needy, that don't necessarily live a long time.

[00:41:13] Dr. Charlene Harrington: Yes.

[00:41:14] Bob: And that creates these crazy incentives.

[00:41:17] Dr. Charlene Harrington: Yes.

[00:41:18] Bob: Wow. And as we saw in the Novus case, there are also people in the caregiving business who have incentives to push patients towards certain hospice providers. That means families must always question the advice they're getting and do their own research.

[00:41:35] Dr. Charlene Harrington: You can't always trust people that refer you to a hospice, because sometimes they're getting fees, what we call kickback fees, to refer patients to particular hospices. And that's why you need to take, the family needs to take time to really find the, the best hospice they can find for the situation.

[00:42:04] Bob: So some people who tell you, this is a good hospice, they have a hidden agenda.

[00:42:08] Dr. Charlene Harrington: Yes, they're actually, sometimes physicians are actually on the payroll of that particular hospice, or they're getting fees for making those referrals.

[00:42:22] Bob: Fortunately, there are some good tools for families to protect themselves and help them do that research.

[00:42:28] Dr. Charlene Harrington: Before you select the hospice, I would strongly urge that the families look on the internet and go to Medicare Hospice Compare. And that is the Medicare's oversight information on hospices. And there are two types of information they have there. One is the patient experience; so it's a survey Medicare does about the hospice care after a patient passes away. And the second one is the quality of patient care. So you should look at that information, and you can compare across hospices. But there's a second piece of information that's very valuable, and that is going to the state licensing and certification program on the internet, and looking up hospices in the state. And the states usually have information on the number of complaints and the number of deficiencies that they've given to hospices. And that's crucial because if any hospice has deficiencies and complaints, I would very much stay away from that particular hospice.

[00:43:55] Bob: It bears repeating, hospice can be a wonderful, crucial service. We don't want stories like this Novus scandal to scare people away from considering hospice. But it is important to have a clear understanding of the risks.

[00:44:10] Dr. Charlene Harrington: Well the, the end of life is, is the most challenging situation I think that certainly a, the patient will face, and it's challenging for the providers to provide good end of life care. It's so important to make people comfortable and try to be, communicate with them and give them the emotional support as well as the actual care support that they need. So each patient is a little different, and this care is quite complex. And you want to have caring professional provide the service, and not get into a situation where you have a hospice company that's just trying to make money and giving the least amount of care possible.

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[00:45:16] Bob: If you have been targeted by a scam or fraud, you are not alone. Call the AARP Fraud Watch Network Helpline at 877-908-3360. Their trained fraud specialists can provide you with free support and guidance on what to do next. Thank you to our team of scambusters; Associate Producer, Annalea Embree; Researcher, Sarah Binney; Executive Producer, Julie Getz; and our Audio Engineer and Sound Designer, Julio Gonzalez. Be sure to find us on Apple Podcasts, Spotify, or wherever you listen to podcasts. For AARP's The Perfect Scam, I'm Bob Sullivan.

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