Transcript Corporate Compliance - Hospice of the Bluegrass

Corporate Compliance
Eugenia Smither, RN, BS, CHC
Corporate Compliance Officer
Vice President of Compliance and
Quality Improvement
Acronyms
• (D)HHS- Department of Health and Human
Services
• OIG- Office of Inspector General
• NH- Nursing Homes
• GIP- General Inpatient Level of Care
• CMS- Centers for Medicare and Medicaid
Services
• IDG- Interdiciplinary Group/Team
• HOB- Hospice of the Bluegrass
*Other abbreviations and acronyms should be addressed
within the presentation
Definition of a Compliance
Program
“A comprehensive strategy to
ensure an organization
consistently complies with
applicable laws relating
to its business activities.”
- National Health Lawyers Association
Definitions
ABUSE –
FRAUD –
“Any incident or
“Intentional deception
practice inconsistent
or misrepresentation
with accepted &
which an individual or
sound medical,
entity makes, knowing
business, or fiscal
it to be false & that
practices which
the deception could
directly or indirectly
result in some
results in
unauthorized benefit.”
unnecessary costs to
the benefit program.”
Why have a
Compliance Program ?
Helps identify intentional criminal &
unethical conduct
Helps identify weaknesses in internal
systems & management structures
Encourages staff to report concerns
internally, rather than externally
Allows for investigation of potential
problems
Rationale for a Compliance
Program
Individual members of management can
be liable under the “responsible officer
doctrine” for illegal acts by employees
under their supervision
Board members can be liable for breach of
fiduciary duty if they do not ensure that
management had proper procedures in
place to avoid violations of law
Responsible to report both to the Secretary of
HHS & to Congress:
•
•
Program & management problems
Make recommendations to correct them.
• Duties are carried out through:
• Audits
•
•
•
Investigations
Inspections
Other mission-related functions performed by
OIG components (divisions).
In October 1999, published the OIG Compliance
Program Guidance for Hospices
OIG Risk Areas
 Uninformed consent to elect the Medicare
Hospice Benefit
 Admitting patients who are not terminally ill
 Arrangement with another provider who hospice
knows is submitting claims for services already
covered by the Medicare Hospice benefit
 Underutilization
 Falsified medical records or plans of care
 Untimely &/or forged physician certifications on
plans of care
 Inadequate or incomplete services rendered by
the IDG
OIG Risk Areas
 Insufficient oversight of patients, those receiving
more than six consecutive months of hospice care
 Hospice incentives to actual or potential referral
services (physicians, NH, hospitals, patients) that
may violate the anti-kickback statute or other similar
regulations, including improper arrangements with
NH
 Overlap in the services that a NH provides, which
results in insufficient care by the hospice
 Improper relinquishment of core services &
professional management responsibilities to NH
homes, volunteers & privately-paid professionals
OIG Risk Areas
 Providing hospice services in a NH before a contract
has been finalized, if required
 Billing for a higher level of care than was necessary
 Knowingly billing for inadequate or substandard care
 Pressure on patient to revoke the benefit when
patient is eligible for & desires care, but care has
become too expensive for hospice to deliver
 Billing for hospice care provided by unqualified or
unlicensed clinical personnel
 False dating of amendments to medical records
 High pressure marketing to ineligible beneficiaries
OIG Risk Areas
 Improper patient solicitation activities such as
“patient charting”
 Allowing the hospice to review records to find their own patients- hospice patients must
be referred not found
 Inadequate management & oversight of
subcontracted services, which results in improper
billing
 Sales commission based on length of stay in hospice
 Deficient coordination of volunteers
 Improper indication of the location where hospice
services were delivered
Why We’re on the OIG Radar
• When the hospice benefit was created in
1982, Medicare did not cover more than 210
days of hospice care per beneficiary.
Congress changed the benefit to eliminate
the limit on the number of days covered by
Medicare.
• Since then, the number and types of
diagnoses associated with hospice utilization
have increased, and longer stays have
become more common.
• The number of for-profit hospices now
exceeds not- for –profit hospices
OIG Workplan
• Each year, the OIG develops a work plan
by provider type
• Areas of focus are outlined, and what the
OIG intends to do about it
• Addendum to this orientation module will
highlight the current areas of focus for the
current year
• Focus continues on GIP, NH, eligibility
Laws & Regulations
Administrative Sanction & Exclusion
Anti-Kickback Statute
Antitrust Laws
Balanced Budget Act
Deficit Reduction Act
False Claims Act
Fraud and Abuse Statutes/Illegal
Remuneration Statutes
Medicare Conditions of Participation
©Harry Hynes
Memorial Hospice,
2011
Environmental Forces Impacting
Hospice Agencies
FEDERAL LEVEL
Payment Error Rate
Measurement
(PERMS)
Comprehensive Error Rate Testing
(CERTS)
Conditions of Participation (CoPs)
42 CFR Part 418
US Congress
REGIONAL LEVEL
STATE LEVEL
NGS
FI
Centers for Medicare &
Medicaid Services
Dept. of Aging
(CMS)
Office of
Inspector General
Health &
Environment
Hospice
State Medicaid
Surveyors
Cigna
(MAC)
NHIC (MAC)
(OIG)
Medicare Payment
Advisory Commission
US Dept. of Health &
Human Services
Medicare Administrative
Contractors
(MACs)
(DHHS)
Health Care Fraud Prevention &
Enforcement Action Team
Office of Ass’t Secretary for Planning &
(HEAT)
Evaluation
(ASPE)
Hospice & Palliative Care
State Organizations
US Government
Accountability Office
(GAO)
Medicaid Integrity Contractors
(MICS)
Cahaba GBA
(FI)
Zone Program
Integrity Contractors
(ZPICS)
Palmetto
(MAC)
CMS Regional
National Hospice & Palliative Care
Organization
(NHPCO)
(MedPAC)
Recovery Audit Contractors
(RACS)
Oversight by Compliance & Legal
as records are submitted
DOJ
OIG
OVERSIGHT
ZPIC/PSC
Legal
Oversight
MIC
FI/Carrier/MAC
RAC
Compliance
Oversight
QIO
Routine
Business
CERT
Source: Strafford Publishing
RISK
Regional Home Health Intermediaries (RHHI)
Fiscal Intermediaries (FI)
Medicare Administrative Contractors (MACs)
• Medicare Modernization Act of 2003
– Transition from FI/carriers to a competitive bid process
– Contracts rebid every 5 years
• Transition period 2005 – 2011
• Benefits to CMS:
– Improved beneficiary services (less contractors +
consistency)
– Improved provider services
• simplified
• competition=better service, financial management, more
accurate claims processing, consistency in payment
decisions
www.cms.gov/MedicareContractingReform
Comprehensive Error Rate Testing
(CERT)
• Paid Medicare claims randomly selected
• Requests medical records to determine provider
compliance with Medicare coverage, coding and
billing requirements
• Assigns error to claim if denied & instructs
FI/MAC to take back money and sends provider a
demand letter for that money
• Appeal process for CERT denials is the same as
the appeal process for Carrier/FI/MAC denials
• Calculates an error rate for each MAC
• CERT does not measure fraud
www.cms.gov/CERT
Payment Error Rate Measurement
(PERM)
• Measures improper Medicaid payments
• Perform statistical calculations, medical
records collections and medical/data
processing review
• Three contractors providing a 17-state
rotation
– Each state reviewed once every 3 years
– Allows States to plan in advance
www.cms.gov/PERM
Quality Improvement Organizations
(QIO)
53 QIOs: one for each state, territory, and Washington DC.
A QIO is a group of practicing doctors and other health care
experts that:
– Ensure that payment is made only for medically
necessary services
– Review the quality of care provided to Medicare
beneficiaries
– Review Medicare beneficiary appeals of certain provider
notices
– Investigate Medicare beneficiary complaints about
quality of care
– Review potential anti-dumping cases
– Implement quality improvement activities as a
result of case review activities
Recovery Audit Contractors
(RACs)
Tax Relief and Healthcare Act of 2006
Detect and correct past improper payments so that
CMS, Carriers, FIs, &/or MACs can implement
actions to prevent future improper payments:
• Providers can avoid submitting claims that do not
comply with Medicare rules
• CMS can lower its error rate
• Taxpayers and future Medicare beneficiaries are
protected
• RAC’s are paid on a contingency basis
– Incentivized to take back Medicare funds
www.cms.gov/RAC
Medicaid Integrity Contractors
(MICs)
Review Medicaid claims for:
• Inappropriate payments
• Fraud
• Identify areas of risk
Similar to RACS – use data analysis, however:
– No limit on # of claims
– Look back period based on State laws
– Not paid on contingency, but eligible for
bonuses
• Required to provide education
www.cms.gov/ProviderAudits
Healthcare Fraud Prevention and
Enforcement Action Team (HEAT)
• Announced May 2009
• Joint operation of Dept. of Health & Human Services
( DHHS) and Dept. of Justice (DOJ)
• Supported by Obama included in 2011 budget request
• Mission of HEAT
– Prevent waste, fraud & abuse in Medicare & Medicaid
programs
– Reduce skyrocketing healthcare costs while improving quality
of care
– Highlight best practices
– Utilize “Strike Forces” to reduce fraud and recover taxpayer
dollars
www.hhs.gov
www.stopmedicarefraud.gov
www.justice.gov
Zone Program Integrity Contractors
(ZPICs)
In 2008, consolidated PSC (Program Safeguard Contractor)
with MEDIC (Medicare Drug Integrity Contractor) to form
ZPICs
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–
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Fraud & abuse through data analysis & audits
Prepay and/or post pay review
Announced/unannounced onsite visits
Determine actual/extrapolated overpayments
All Part of Medicare - A, B, C, D
Provide support to law enforcement
Refer providers from Medicare exclusion
Identify areas of risk
Ky in Zone 4
The Quality Assessment
Performance Improvement
Plan
Assists in Compliance by:
Monitoring Activities
Policy and Procedures
Employee Training
and Participation
Code of Conduct
Directs our conduct within ethical & legal
standards.
 Helps us understand our ethical and
legal responsibilities.
 Applies/outlines appropriate relationships
with our partners:
Patients/Families, MD’s, affiliated providers, third
party payers, subcontractors, contractors,
vendors, suppliers, consultants, colleagues,
volunteers, communities, donors, regulators
Code of Conduct
HOB’s mission and ethical requirements
HOB’s commitment to comply with federal, state,
and private insurer standards & our partners
Outlines leadership responsibilities
Directs us in response to inappropriate/unlawful
behavior
Addresses disruptive behavior and
organizational response
Defines Environmental Compliance
Political activities
Marketing practices
Compliance Plan
Lists how we address the “Seven Elements” of
an effective compliance program
Work plan is developed based on our risks
Lists the OIG Risk Areas, Applicable Laws and
Regulations
Supported by HOB policies
Address regulatory compliance
Address accreditation process
Financial reporting and records (internal controls)
Business courtesies (receiving, extending)
Outlines handling of business information/systems
Antitrust, Information re: Competitors, Truthful
Advertising
Reporting Process
Open lines of communication with
Corporate Compliance Officer
 Hotline Telephone # (859) 275-1126 or
(800) 798-4146 or e-mail
[email protected]
 Suggestion Box in every office, internet and
intranet
 HHS-OIG Hotline # (800) 447-8477 or (1-800-HHSTIPS)
Joint Commission (safety or quality of care)
(630) 792-5000 or 1-800-994-6610 or e-mail
[email protected]
 Confidentiality (effort will be made to ensure staff
confidentiality in reporting and during investigations)
 No retaliatory disciplinary action against employees who
report safety or quality concerns to Joint Commission, or
internally
Internal Investigation
May include:
Interviews with management personnel,
staff, patient, contractors, and agencies
Review of relevant documents
Engagement of legal counsel, auditors or
other health care experts
Subsequent review for similar problems
Reporting to Authorities
Have a duty to report when required
Federal and State authorities promptly notified
Timeframes vary, depending on the issue
 5 days to 30 days
Any reporting would be done under the advice of
counsel
Provide all relevant evidence and any potential
cost impact
Report disciplinary actions taken and changes to
the Compliance Plan
Violations
Includes non-compliance to the Code of
Conduct, other HOB policies or violation
of any Federal or State Statute or any
Federal program regulations
Actions to be fair & equitable
Actions to be determined case-by-case
Actions may result in termination of
employment or contractual arrangement
Disciplinary Process
The Corporate Compliance Officer will bring
the offense/violator before the Committee
which will decide the degree of disciplinary
action, if any.
Verbal warning
Written warning
Written reprimand
Suspension
Termination
Restitution
Thank- you!!!
• Feel free to contact the Compliance
Officer with any questions
• 859-276-5344 [email protected]
– [email protected]
Commit to “Doing the Right Thing”.
Obey the regs and policies that apply to your job.
Make compliance awareness part of your job.
Put your Code of Conduct in an accessible spot.
Lead by example.
If in doubt, check it out.
Attend training sessions.
Notify supervisor of possible wrongdoings.
Communicate openly & honestly.
Ethics is a part of all activities.