Reducing Risk Through A Strong Compliance Program Lisa Meadows/MSW Clinical Compliance Educator Accreditation Commission for Health Care

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1 Reducing Risk Through A Strong Compliance Program Lisa Meadows/MSW Clinical Compliance Educator Accreditation Commission for Health Care 1 Objectives Review OIG s recommendations for a Compliance Program Identify daily practices of staff that may lead to fraudulent behavior Explore ways to educate staff on compliance issues 2 Why do this? Voluntary participation at this time Increased scrutiny on fraud & abuse in health care Sets a good foundation that covers multiple facets of home care Ultimately, want to create a culture of compliance 3 MEADOWS, LISA 1

2 What Does a Culture of Compliance Look Like? Requires Board level commitment Corporate Responsibility and Corporate Compliance: A Resource for Health Care Boards of Directors Staff awareness Top level to direct care staff A system of checks and balances 4 OIGs Recommendations Implementing policies & procedures and standards of conduct procedures Designating a compliance officer & committee Conducting effective training and education Developing effective lines of communication (hotline for staff) 5 OIGs Recommendations Enforcing standards through well-publicized disciplinary guidelines Conducting internal monitoring and auditing Responding promptly to detected offenses and developing corrective action Federal Register 1999 Hospice Federal Register 1998 Home Health 6 MEADOWS, LISA 2

3 Policies & Procedures and Standards of Conduct How strong are your policies? Not just clinical or operational policies need strong HR policies. Do they cover just the basics or are they proactive in nature? Well written or ambiguous? Do staff know where they are? Process for creating, revising, deleting? 7 Policies & Procedures and Standards of Conduct Need to include: Clinical Evidenced based clinical practice Operational The how and why of what we do Eligibility, discharge & revocation criteria Hospice Medicare Benefit Medicare Home Health Benefit Billing practices 8 Policies & Procedures and Standards of Conduct Human Resource Standards of conduct- Ethical component Disciplinary procedures Billing for items or services not rendered or medically necessary 9 MEADOWS, LISA 3

4 Compliance Officer & Committee Needs to be a designated person; part of their job description Likes rules & regulation Strong knowledge of CoPs, State Regulation, Medicare/Medicaid/Private Insurance regulation, compliance issues Stay on top of regulation Committee oversight Checks and balances 10 Training and Education Starts with orientation Ongoing Annual How it relates to their day to day practice Real life examples Scripting Role playing 11 Effective Lines of Communication Hotline that is anonymous Safeguards for reporting Whistleblowers; listen to them Disciplinary action for false allegations Learning opportunities 12 MEADOWS, LISA 4

5 Publicized Disciplinary Guidelines Staff need to clear on what is acceptable and what is not acceptable Progressive discipline Accountability Staff need to see a process/system that works Benefit of office gossip 13 Internal Monitoring and Auditing Checks and balances What can your software do? Manual checks Tracking Follow up Process issue vs. personnel issue Assess the effectiveness of your compliance program Capturing the door closers 14 Responding to Detected Offenses and Developing Corrective Action Acknowledge Self report Overpayments Seek legal counsel if appropriate Put systems in place to prevent further issues Educate staff 15 MEADOWS, LISA 5

6 Fraud vs Abuse Fraud is defined as making false statements or representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist. Acts may be committed either for the person s own benefit or for the benefit of some other party. In other words, fraud includes the obtaining of something of value through misrepresentation or concealment of material facts. 16 Fraud vs Abuse Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse includes any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and are fairly priced. Both fraud and abuse can expose providers to 17 criminal and civil liability. False Claims Act The FCA (31 United States Code [U.S.C.] Sections ) protects the Government from being overcharged or sold substandard goods or services. The FCA imposes civil liability on any person who knowingly submits, or causes to be submitted, a false or fraudulent claim to the Federal Government. 18 MEADOWS, LISA 6

7 False Claims Act The knowing standard includes acting in deliberate ignorance or reckless disregard of the truth related to the claim. 19 Risky Behaviors of Staff HOSPICE Billing errors Change in level of care Proper communication & documentation Overpayments Prescription Drugs (OIG Report) Over use of GIP (2012 & 2013 Work Plan) Admitting inappropriate patients, knowingly 20 Risky Behaviors of Staff Inappropriate revocation Inappropriate marketing practices (OIG 2012 Work Plan) Not providing all members of the team to meet the patients needs 21 MEADOWS, LISA 7

8 Risky Behaviors Specific to Hospice & SNF Offering free goods or goods at below fair market value to induce a nursing home to refer patients to the hospice. Paying room and board payments to the nursing home in amounts in excess of what the nursing home would have received directly from Medicaid had the patient not been enrolled in hospice. Paying amounts to the nursing home for additional services that Medicaid considers to be included in its room and board payment to the hospice. 22 Risky Behaviors Specific to Hospice & SNF A hospice providing staff at its expense to the nursing home to perform duties that otherwise would be performed by the nursing home. A hospice referring its patients to a nursing home to induce the nursing home to refer its patients to the hospice. 23 OIG Report 81% percent of hospice claims for beneficiaries in nursing facilities did not meet at least one Medicare coverage requirement pertaining to election statements, plans of care, services, or certifications of terminal illness. Most commonly, the statements did not explain that hospice care was palliative rather than curative or that the beneficiaries waived Medicare coverage of certain services related to their terminal illnesses. 24 MEADOWS, LISA 8

9 OIG Report 63% of claims did not meet plan of care requirements. These plans of care were not established by an interdisciplinary group; they did not include necessary components, such as a detailed description of the scope and frequency of services; or they did not specify intervals for review, as required. 25 OIG Report 31 % of claims, hospices provided fewer services than outlined in beneficiaries plans of care. Most commonly, the hospices provided services to the beneficiaries but not as frequently as called for in the plans of care. In the most extreme cases, there was no documentation in the medical records of any visits for a particular service. 26 Risky Behaviors of Staff HOME HEALTH Billing Items or services not rendered Medically unnecessary services Duplicate billing False cost reports Credit balances-failure to refund 27 MEADOWS, LISA 9

10 Risky Behaviors of Staff Incentives to actual or potential referral sources Joint ventures Stark physician self referral law 28 Risky Behaviors of Staff New for Home Health OIG 2013 Work Plan Face to Face Hiring of Home Health Aides with previous convictions Missing or incorrect OASIS data 29 Fraud or Abuse? Late documentation Contemporaneously Any medical records that contain amendments, corrections, or addenda must: Clearly and permanently identify any amendment, correction or delayed entry as such, and Clearly indicate the date and author of any amendment, correction, or delayed entry, and Not delete, but instead, clearly identify all original content. Medicare Advisory, Palmetto, Feb MEADOWS, LISA 10

11 Staff Awareness Educate all staff Areas for potential fraud & abuse Hospice Medicare Benefit Medicare Home Health Benefit Eligibility criteria Internal policies & procedures Script & role play Sticky situation responses 31 Resources Federal Register Vol. 64, No. 192/October, 1999 HSP Federal Register Vol. 63, No. 152/August, 1998 HH HHS OIG Work Plan FY 2013 HHS OIG Work Plan FY 2012 HHS OIG Work Plan FY 2011 HHS OIG Work Plan FY 2010 HHS OIG Report, Medicare Could Be Paying Twice for Prescription Drugs for Beneficiaries in Hospice June, 2012 NHPCO NewsBriefs 32 Questions? 33 MEADOWS, LISA 11

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