Kusserow on Compliance: CMS issues final rule on affiliation disclosure requirements for the provider enrollment process

CMS issued a final rule on September 10 that sets forth requirements mandating providers and suppliers who submit an application for enrollment or revalidation for Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP) disclose current or previous (up to five years) affiliations with a provider or supplier who has uncollected debt; has been or is subject to a payment suspension under a federal health care program; has been excluded from participation from Medicare, Medicaid, or CHIP; or has had billing privileges denied or revoked. CMS said a history of bad actors trying to escape the ramifications of inappropriate or fraudulent behavior by re-entering the program in some capacity, and/or shifting their activities to another enrolled Medicare provider or supplier with which they are affiliated, provided the motivation for the rule. In addition to furnishing the disclosure information, the provider must submit: (a) an organizational diagram identifying all of the entities listed in this section and their relationships with the provider and with each other; and (b) if the provider is a skilled nursing facility, a diagram identifying the organizational structures of all of its owners.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Successful investigation interviews require proper preparation

Proper preparation is the number one factor for a successful interview. Do not rush into an interview until you are fully prepared. It is important to examine and understand all the facts known that relate to the matter under investigation. It is also critical to understand what information is needed to advance the investigation and to determine what the person being interviewed can contribute to this. The following tips will help ensure best results:

  1. Develop an investigation plan. Before any interviews, it is important to (a) set investigative priorities/objectives; (b) review what is known; (c) obtain needed documents; and (d) identify those people that should be interviewed, in what order.

 

  1. Master the known facts of the case. Review all the available facts and evidence; and decide what you need from witnesses to prove the offense or fill gaps.

 

  1. Properly prepare for each interview. A successful interview includes knowing who should be interview, their background, what information they may have to advance the investigation, and what documents are relevant to their interview.

 

  1. Develop an outline for each interview of the points to be covered in a logical manner. It should be in an abbreviated form, serving as a road map to keep things on track by addressing different topics to be covered. However, rigid adherence to an outline or detailed questions is not advisable, as it will tend to distract the interviewer from carefully listening to the witness’s answers and generating useful follow up questions.

 

  1. Schedule interviews as quickly as possible. Interviews of witnesses should be scheduled in a logical order to build a case, as soon as possible, before memory fades or is influenced by events.

 

  1. Have relevant material on hand during the interview. Have only documents present that are relevant to the interview. As appropriate, show the witness the relevant documents and let him or her review them before answering. It may assist in refreshing memory of events.

 

  1. Use copies of original documents for interviews. As a rule, it is best to keep original evidence secured in a controlled access location. Using copies will ensure that original ones are not lost or compromised.

 

  1. Take care in selecting the location and setting for the interview. Schedule interviews away from the persons work station or office. The setting for the interview should be in a place where it cannot be overheard or where there are distractions in sight and sound. As such, the person should not be near a window. It is also advisable to avoid barriers with the interviewee, such as table and desks, that may be viewed as overly formal and threatening.

 

  1. Allow adequate time for the interview to be conducted in an appropriate environment. Most interviews in complex cases take much longer than the witness anticipates. Conduct the interview in a professional environment; do not attempt to interview an important witness at lunch or in another social setting.

 

  1. Review policy regarding rights of employees during an investigation. Check with HR before conducting employee interviews to determine if employees who decline to cooperate could/would be considered insubordinate, as well as whether employee rights exist that may restrict interviews. For example, members of unions may have the right to be present and to take independent notes and/or record the meeting.

Richard Kusserow has over 40 years investigative experience including eleven years as HHS Inspector General and twelve years with the FBI. He authored “Conducting Internal Investigations in Health Care Organizations (ISBN 979-1-936230-60-8). His firm provides investigator training for clients.

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Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: OIG Work Plan update on Hospital Sector

The HHS Office of Inspector General (OIG) Work Plan sets forth various audits and evaluations that are underway or planned during the fiscal year and beyond. Since June 2017, the OIG modifies the plan monthly to add new items and remove completed ones. When developing its plans, the OIG assesses relative risks in HHS programs and operations to identify those areas most in need of attention. The OIG recently reported updates to its planned work in the hospital sector that include:

  1. Determining whether: (1) skilled nursing facility (SNF) level of care was certified by a physician or a physician extender; (2) a condition treated at the SNF was one which the beneficiary received inpatient hospital services or a condition that arose while receiving care in a SNF; (3) daily skilled care was required; (4) services delivered were reasonable and necessary for the treatment of a beneficiary’s illness or injury; (5) improper Medicare payments were made on claims reviewed; and (6) hospital admissions were potentially avoidable.

 

  1. Reports on a data brief that describes nursing staffing levels reported by facilities to the Payroll‐Based Journal; examination of CMS’s efforts to ensure data accuracy and improve resident quality of care.

 

  1. Determining whether CMS corrected the common working file (CWF) edits and ensured they are working Prior review found that CMS CWF edits related to transfers to home health care, SNFs, and non‐IPPS hospitals were not working properly.

 

  1. Review of overstated Medicare charges on outpatient claims that contain both an outlier payment and a reported medical device credit to determine whether Medicare payments for replaced medical devices and their respective outlier payments were made in accordance with Medicare requirements.

 

  1. Determine how inpatient hospital billing has changed over time and describe how inpatient billing varied among hospitals and will use results to target certain hospitals or codes for a medical review to determine the extent to which the hospitals billed incorrect codes.

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on LinkedIn.

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Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: GAO reports CMS gaps in nursing home oversight

CMS needs to address gaps in federal oversight of nursing home abuse investigations

The Government Accountability Office (GAO) reviewed CMS oversight of nursing home abuse in response to a request from the Congress. As part of its review, the GAO interviewed officials from survey agencies about how they investigate complaints and facility-reported incidents of resident abuse in nursing homes in five selected states.

The GAO noted, there are approximately 15,600 nursing homes providing care to about 1.4 million nursing home residents, a population of elderly and disabled individuals. CMS defines the standards nursing homes must meet to participate in the Medicare and Medicaid programs, including standards for resident care and safety. To monitor compliance with these standards, CMS enters into agreements with state survey agencies to conduct standard surveys or evaluations of the state’s nursing homes. Those surveys and evaluations investigate both complaints from the public and facility-reported incidents regarding resident care or safety, such as abuse. Investigations of nursing homes based on public complaints and facility-reported incidents offer a unique opportunity for the state survey agencies to identify potential abuse, as these can provide a timely alert of acute issues that otherwise might not be addressed until the standard survey.  Federal nursing home surveys and investigations of complaints and facility-reported incidents can be cited and tracked by CMS. Where deficiencies are found, CMS can impose federal sanctions to prompt the correction of deficiencies.

The review focused on Oregon, a state with 135 nursing homes caring for approximately 7,000 residents. The GAO found failure to follow federal requirements that the survey agency investigate all complaints and facility-reported incidents. Additionally, the GAO found CMS failed to address gaps in federal oversight in Oregon for at least 15 years. The GAO suggested to CMS that these problems may extend to other states and that CMS needs to take corrective action.

GAO recommendations to the administrator of CMS included: (1) evaluating state survey agency processes in all states to ensure all state survey agencies are meeting federal requirements that state survey agencies are responsible for; (2) investigating complaints and facility-reported incidents alleging abuse in nursing homes; and (3) that the results of those investigations are being shared with CMS.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2019 Strategic Management Services, LLC. Published with permission.