SNF Compliance Programs: What s at Stake?

Transcription

1 SNF Compliance Programs: What s at Stake? HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Kris Mastrangelo, OTR/L, LNHA, MBA President and CEO About Kris Kris Mastrangelo, OTR/L, LNHA, MBA Kris Mastrangelo, President and CEO, owns and operates Harmony Healthcare International, (HHI) an industry leader in Long Term Care consulting. Healthcare Specialist 14,000 Medical records reviewed per year Core Business Patient Centered Follow Copyright 2015 All Rights Reserved Harmony Healthcare International, Inc. 2 Wall Street Journal, November 12, 2012 Thomas Burton, November 2012 More intensive services were done than actually performed Patients could not benefit from it Cutting fraud Obama Copyright 2015 All Rights Reserved Harmony Healthcare International, Inc. 3 1

2 OIG Report: Claims in 2009 Billing Errors Issues found with skilled-nursing facilities Medicare claims, based on an outside review of 2009 data 20.30% Billed for a more expensive treatment than was provided 2.50% Billed for a less expensive treatment than was provided 75.10% Properly billed 2.10% Billed for a condition not covered by Medicare Source: Department of Health and Human Services Office of Inspector General Copyright 2015 All Rights Reserved Harmony Healthcare International, Inc. 4 Compliance Programs Critical changes have occurred with the False Claims Act Most noteworthy change; Leaders be advised! Revision of the "intent" to submit an incorrect claim Copyright 2015 All Rights Reserved Harmony Healthcare International, Inc. 5 Compliance Programs Providers have only 120 days to correct MDS errors and submit a billing adjustment for Medicare Part A claims Late identification of billing errors yields mandatory self disclosure within 60 days of overpayment identification It is a felony not to return the payment The civil penalty for the aforementioned is $5,500 to $11,500 per false claim along with three times the amount of damages which the government sustained Copyright 2015 All Rights Reserved Harmony Healthcare International, Inc. 6 2

3 Seven Elements of Compliance P-R-E-P-A-R-E Policies and Procedures Reporting and Investigating Education and Training Prevention and Response Auditing and Monitoring Responsibility/Oversight of Compliance Officer/Committee Enforcement, Discipline and Incentives Copyright 2015 All Rights Reserved Harmony Healthcare International, Inc. 7 High Risk Areas Quality of Care Resident Rights Billing & Claims Submission Employee Screening Kickbacks, Inducements and Self-Referrals Cost Reporting HIPAA Privacy and Security Record Creation and Retention Anti-Supplementation Copyright 2015 All Rights Reserved Harmony Healthcare International, Inc. 8 Risk Assessment Determine risk areas Prioritize on severity, likelihood and impact Ongoing assessment Best Practice Changes in Policy Medicare MDS Therapy Copyright 2015 All Rights Reserved Harmony Healthcare International, Inc. 9 3

4 Comparative Data-FY th 50th 80th Target Area Percentile Percentile Percentile Therapy RUG Days 85.5% 93.2% 97.3% Ultra High RUG Days 28.1% 53.9% 73.1% Therapy High ADL Days 20.0% 32.9% 48.1% Non Therapy High ADL Days 11.5% 23.4% Day Episode of Care 7.5% 14.1% 25.9% Change of Therapy Assessments 7.0% 12.7% 19.0% Copyright 2015 All Rights Reserved Harmony Healthcare International, Inc. 10 HHI Analysis FY 2013 PEPPER ANALYSIS Harmony Healthcare International (HHI) 430 Boston Street, Suite 104, Topsfield, MA MAC: NHIC Percentile Ranking Jurisdiction Target Areas Target Count Percent National (MAC) State Therapy High ADL Days 2, % Non-Therapy High ADL Days % Change of Therapy Assessments % Ultra High RUG Days 3, % Therapy RUG Days 5, % Day Episode of Care % th Percentile 20th Percentile Copyright 2015 All Rights Reserved Harmony Healthcare International, Inc. 11 HHI Comparative Data National Comparative Data (Actual Percentages) Percent 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Therapy RUG Ultra High Therapy High Non Therapy 90+ Day Days RUG Days ADL Days High ADL Episode of Days Care Target Areas Change of Therapy Assessments 80th Percentile Actual SNF 20th Percentile Copyright 2015 All Rights Reserved Harmony Healthcare International, Inc. 12 4

5 Questions/Answers Harmony Healthcare International (978) Healthcare.com Connect facebook.com/harmonyhealthcareinternational H linkedin.com/company/harmony-healthcare Copyright 2015 All Rights Reserved Harmony Healthcare International, Inc. 13 SNF Compliance Programs: The Role of Quality of Care Corporate Integrity Agreements FELICIA E. HEIMER SENIOR COUNSEL, OFFICE OF INSPECTOR GENERAL U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES What is a Quality of Care CIA? Agreement to establish and maintain a compliance program Standard requirements in all CIAs include: Compliance Officer and Committee Board of Directors obligations Written standards and policies Training program Independent Review Organization Disclosure Program Screening for Ineligible Persons Reporting 5

6 What is a Quality of Care CIA? Tailored Provisions for Quality of Care CIAs Expanded elements to include quality assurance and improvement Quality of Care Dashboard Internal Quality of Care Review Program Independent Monitor Novel Provisions in Recent CIAs Providers should review Quality of Care CIAs for new provisions and consider implementing them within their organizations When Does OIG Negotiate Quality of Care CIAs? Release of exclusion authority under section 1128(b)(6)(B) of the Social Security Act Fraud cases involving quality of care o Systemic care failures Central to the Decision - Best Interests of Beneficiaries Examples of provider types o Nursing homes o Hospitals o Behavioral health providers o Dental providers Independent Monitor - OIG Perspective What is an Independent Monitor? Assesses provider s internal quality assurance and improvement systems Resource, not adversary Focuses on process and systems Broad Authority Not a survey 6

7 How Does OIG Monitor Quality of Care CIAs? CIA signals change in relationship with OIG OIG attorney assigned to monitor CIA and provider Key elements must be established and implemented within 60 to 120 days Close communication with Independent Monitor Implementation and Annual Report submissions Review of Reportable Events Site visits Continual assessment of improvement Fundamental Inquiries Is the provider committed to setting up and maintaining an effective compliance program? Is the Compliance Officer qualified to oversee the program? Does the Compliance Officer have sufficient standing and resources to maintain an effective compliance program? Is the provider receptive and responsive to the Independent Monitor? Is the provider capable of implementing the Independent Monitor s recommendations? Monitoring and Quality Improvement: Experiences and Insights at the Bedside and the Boardroom David R. Zimmerman, Ph. D. University of Wisconsin Madison Long Term Care Institute 7

8 Agenda Review of OIG Monitoring Experience Some Insights Gained from the Experience Integrating Internal Quality Improvement (IQI) and External Quality Assurance (EQA) CIA Monitoring Experience Monitor for 24 corporate CIA s 6 national corporations More than 2300 nursing home visits in monitoring and research roles Attended > 100 regional QA meetings ~ 30 corporate level QA meetings ~ 20 board or board committee meetings Independent Monitor Assesses effectiveness of Internal System for Quality Assurance and Improvement Adequacy of Infrastructure, Policies and Procedures, Training, and Internal Monitoring At all levels of the organization Quality of Care is one of the measures of system effectiveness But not the only one The focus is also on the internal quality assurance and improvement system in the corporation 8

9 Internal Systems Perspective Ability of the system to: Identify problems Determine scope and system-wide improvement opportunities Create effective corrective plans and disseminate through system Execute the corrective plans Evaluate whether the above elements are adequate Are the systems proactive or only reactive? Facility Visit Protocols Review Specific Care areas Roughly coincide with regulatory areas Not just clinical; look at quality of life culture example: resident-staff interaction Person-centered care Also review general systems and processes Eg: QI/PI, training, staffing, communication Also look at super-systems : Decision/admissions policies and systems Change in resident condition, and response Emphasis in Facility Visits Focus is on real-time sharing of information and findings with facility/corporate staff Interaction with facility /corporate staff is constant throughout the visit Summary meeting held to discuss findings; The contents of the summary meeting should never be a surprise. Both monitor and corporate staff involved Focus of the meeting is also on the internal systems of the facility and corporation 9

10 How do we measure performance? Structure Process Outcome Measuring Performance: Outcomes Survey results Resident-based QIs Hotline complaints Events Customer and staff satisfaction Staffing Average Health Deficiency Index Comparison of Health Deficiency Index July 2002 vs April 2006 Monitored Corporations vs Non- Monitored Corporations vs All Other Facilities (excluding divested facilities) Monitored Corporations Non Monitored Corporations in Comparison Group All Other Facilities Average Health Deficiency Index July, 2002 Average Health Deficiency Index April, 2006 Facilities monitored as of 04/06 10

11 Comparison of Percent Severe Deficiencies July 2002 vs April 2006 Monitored Corporations vs Non- Monitored Corporations vs All Other Facilities (excluding divested facilities) Monitored Corporations 21.1% 20.0% 20.6% 18.0% 21.0% 21.6% Non Monitored Corporations in Comparison Group All Other Facilities Percent Severe Deficiencies Average Percent Severe Deficiencies July, 2002 Average Percent Severe Deficiencies April, 2006 Facilities monitored as of 04/06 11

12 As of December 2010 Four national corporations monitored by LTCI: Ranked second, third, fourth, and sixth best of the 12 comparison corporations on average rank of deficiency measures Had more than twice as many QI/QMs that ranked in the best three corporations, compared to the worst three corporations As of September 2013 Four national corporations monitored by LTCI: Ranked second, third, fourth, and eighth best of the 12 comparison corporations on average rank of deficiency measures Lessons learned Focus on internal quality systems is very difficult to achieve and maintain Facilities and corporations are hard-coded to focus on external QA (survey) process This emphasis is especially difficult to achieve in smaller, regional corporations But it is critical to the success of monitoring 12

13 Lessons learned In the long run, systems are more important than leaders Because systems survive leaders Validation is the single most important principle in internal quality improvement And the most difficult to achieve Integrating IQI and EQA: Is the Time Right? Increasing Interest in IQI QAPI, Advancing Excellence, State initiatives (WCRC) Continuing Challenges in the Survey Process Both Industry and Consumer Advocates continue to stress inadequacy of the survey process Budget woes: and things unlikely to get better New Influences: Pay for Performance and Participation in Care Networks Prospects for change in the QI/QA environment More interest in and acceptance of IQI Problems in the survey process One size fits all is being questioned Problems addressing both ends of the distribution High cost of the survey process What to do about Assisted Living 13

14 WCCEAL Wisconsin Coalition for Collaborative Excellence in Assisted Living Set up as a combined internal quality improvement/external quality assurance system Assisted living providers work through their associations to develop a certified QI program WCCEAL Facilities submit data to a central repository and receive reports back Structure Process and Outcome measures Participation can qualify them for reduced survey 14