Kusserow on Compliance: OIG report on vulnerabilities in the Medicare hospice program

15 specific actions recommended to reduce Hospice vulnerability

4 million Hospice beneficiaries with an annual cost of $17 billion

CMS plans to increase hospices reimbursement by $340 million

 

The HHS Office of Inspector General (OIG) reported on numerous evaluations, audits, and investigations of the hospice program that have resulted in questioned costs, as well as criminal and civil prosecutions. The result of this work has identified vulnerabilities in the program. By way of background, the objective of hospice is to provide great comfort and care to beneficiaries, their families, and caregivers at the end of a beneficiary’s life. This program has grown steadily over the past decade, with Medicare now paying about $17 billion annually on behalf of 1.5 million beneficiaries—grown from a half million in 2000. According to CMS, hospice expenditures are anticipated to continue rising 8 percent annually as more beneficiaries utilize the care. In their review of this program, the OIG found:

  1. Hospice providers do not always provide needed services to beneficiaries; sometimes provide poor quality care; and were not able to effectively manage symptoms or medications, leaving beneficiaries in unnecessary pain for many days.
  2. Beneficiaries and their families and caregivers do not receive crucial information to make informed decisions about their care.
  3. Hospices’ inappropriate billing costs Medicare hundreds of millions of dollars that included billing for an expensive level of care when the beneficiary does not need it.
  4. A number of fraud schemes in hospice care negatively affect beneficiaries and the program with some involving enrolling beneficiaries who are not eligible for hospice care, while other schemes involve billing for services never provided.
  5. The current payment system creates incentives for hospices to minimize their services and seek beneficiaries who have uncomplicated needs with a hospice being paid for every day a beneficiary is in its care, regardless of the quantity or quality of services provided on that day.

The OIG recommended that CMS implement 15 specific actions that relate to seven areas for improvement. The OIG called upon CMS to:

  1. Strengthen the survey process-its primary tool to promote compliance-to better ensure that hospices provide beneficiaries with needed services and quality care.
  2. Seek statutory authority to establish additional remedies for hospices with poor performance.
  3. Develop and disseminate additional information on hospices, including complaint investigations, to help beneficiaries and their families and caregivers make informed choices about hospice care.
  4. Educate beneficiaries and their families and caregivers about the hospice benefit, working with its partners to make available consumer-friendly information.
  5. Promote physician involvement and accountability to ensure that beneficiaries get appropriate care.
  6. Strengthen oversight of hospices, including analyzing claims data to identify hospices that engage in practices that raise concerns.
  7. Take steps to tie payment to beneficiary care needs and quality of care to ensure that services rendered adequately serve beneficiaries’ needs, seeking statutory authority if necessary.

Meanwhile CMS announced in proposed rulemaking plans to increase payments for hospices by 1.8 percent, or $340 million, up from $180 million increase last year. CMS also included under the new Proposed rule:

  • New standards to help determine what measures hospices will no longer have to report under its meaningful measures initiative.
  • Changes to the Hospice Compare policies site to correct massive amounts of incorrect addresses, phone numbers and profit status for providers.
  • Beginning January 1, 2019, Hospices will have 4½ months after the end of each quarter to review and correct data that will be reported publicly on the website.
  • Physician assistants will be recognized as attending physicians for Medicare hospice.
  • Aggregate cap limiting overall annual hospice payment will increase by 1.8 percent to $29,205.44.

 

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 Google+ or LinkedIn.

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Copyright © 2017 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: U.S. Sentencing Commission Federal Register Notice seeking public comment

This is time sensitive for those interested in making comments

The U.S. Sentencing Commission published a request for comment in the Federal Register seeking public comment and feedback on its list of tentative priorities for the amendment cycle ending on May 1, 2019. This is part of the annual amendment cycle, during which the Commission reviews and revises its guidelines. This year, the Commission is focusing on whether the time has come to prioritize amending Chapter Eight to cover drug-related offenses. Broadly defined, those offenses might include drug trafficking offenses, misbranding and adulteration of drugs, the sale of unapproved drugs, and dispensing certain drugs without a prescription. The Commission will not make final decisions on this subject until it has heard from the public. As such, those that have thoughts on this topic should consider weighing in with this opportunity of giving them feedback. If adopted, this priority could lead to guideline changes with a potential impact on the pharmaceutical, health care, and certain retail industries.  This may in turn impact the seven standard elements of an effective compliance program, and, in turn, the work of compliance officers.

Therefore, those that have thoughts about the proposed changes have the opportunity to have their ideas brought before the Commission. This includes whether this should be a priority for them now and, if so, how broad or narrow they should be on this issue. One area to consider is whether there are ideas and suggestions as to how the Commission should study this issue area over the next couple of years. At any rate, the Commission has opened the door for public feedback, ideas, and suggestions; however this is time sensitive in that the Commission will make its final decision on priorities at a public meeting in August, after considering all the public comments. If this is something of interest, more information is available at the Commission’s website.

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 Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2017 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: OIG cases involving sanctioned parties and tips to avoid violations

Compliance Officers must screen employees against the List of Excluded Individuals and Entities (LEIE). This is stressed in all of the OIG’s compliance guidance documents. CMS makes it a condition of participation and enrollment. The LEIE continues to change and grow with more than 3,000 exclusions added annually. Failure to screen employees, medical staff, contractors, and vendors results in a great risk. The OIG may consider claims that include work or products from a sanctioned party to be false and fraudulent. Violations can result in monetary penalties. Most cases that deal with this issue are brought to the OIG’s attention through the “Self-Disclosure Protocol.”  In all the recent cases posted, the OIG imposed penalties, but the penalties were mitigated by the fact the matters were self-disclosed—as a result, none of these cases resulted in a Corporate Integrity Agreement (CIA). The OIG posts a number of these cases on its website. The following are examples of recent actions against organizations that engaged individuals they knew or should have known were excluded from participation in the federal health care programs:

  • Southwest Trinity Management, LLC (STM), in Oklahoma paid $141,986.36 in settlement for employing an excluded licensed practical nurse that provided items or services that were billed to Federal health care programs.
  • Diamonds & Pearls Health Services, LLC (DPHS), Cleveland, Ohio paid $75,471.92 for employing an excluded individual who was a scheduling/staffing coordinator, provided items or services to DPHS patients that were billed to Federal health care programs.
  • Center for Ear, Nose Throat & Allergy, P.C. (CENTA) in Indiana, paid $51,564.14 for employing an excluded medical records file clerk, provided items or services to CENTA’s patients that were billed to Federal health care programs.
  • MHMR, Fort Worth, Texas, paid $97,869.78 for employing a program director who had been excluded to provide items or services to clients who were receiving services funded by a Medicaid waiver program.
  • Shawnee Health Services (Shawnee), Carterville, Illinois, paid $107,761.08 as result of employing an excluded individual as a case manager, provided items or services to clients that were receiving services under a Medicaid waiver program.
  • Arkansas Department of Health (ADH) paid $39,343.61 as result of employing an excluded hospice social worker that provided items or services to patients of a community based hospice operated by ADH.
  • Century Pharmacy (Century), Brooklyn, New York, paid $10,000 for an employed excluded individual, who assisted in filling prescriptions in addition to performing other clerical tasks, provided items or services to Century patients that were billed to Federal health care programs.
  • Sundance Behavioral Healthcare System (Sundance), Texas, paid $49,183.48 for an employed sanctioned licensed vocational nurse that provided items or services to patients that were billed to Federal health care programs.
  • ASAP Professional Home Health (ASAP), Houston, Texas, paid $21,797.76 for an employed excluded attendant, provided items or services to ASAP patients that were billed to Federal health care programs.

Practical Screening Tips

  1. Ensure periodic sanction screening of employees, medical staff, contractors, and vendors against the LEIE—best practice is monthly screening.
  2. Inasmuch as most states have developed their own exclusion database, with many states mandating monthly screenings, care should be taken to understand and meet state screening requirements.
  3. Inasmuch as most LEIE exclusions arise from another underlying court, state agency, or licensure board action, it is advisable to also conduct background checks and seek written assurances in applications that prospective employees, contractors, and vendors have not been subject to any prior court or licensure board actions.
  4. It is common for individuals that may be the subject of an investigation, but not yet sanctioned with final actions, to be under investigation for considerable time, therefore it is a best practice to require as a condition of employment, gaining staff privileges, or engagement for the applicant to attest that they have not been, nor are they now, the subject of an investigation by any duly authorized regulatory or enforcement agency. It is also advisable to add a condition that they must promptly report any notice of investigation that involves them.
  5. Educate and inform management and employees on their obligation to promptly report any notification of an adverse action by any duly authorized regulatory or enforcement agency.

Daniel Peake of the Compliance Resource Center (CRC) works with many organizations in ensuring proper sanction screening and from that experience offers a number of practical tips to avoid creating an actionable violation.  He can be reached at dpeake@strategicm.com or (703) 236-9850.

 

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 Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2017 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: A definition of health care compliance

A good starting point for meeting the obligations of a compliance officer’s position is to define health care compliance. This can be useful in developing plans and objectives for the program, as well as explaining the meaning to executive leadership and the board.

  1. Health care compliance is defined as adhering to laws, rules, regulations, and program requirements, as well as the Codes of Conduct, policies, and procedures for the organization. Meeting this definition means identifying and meeting all applicable legal, regulatory, program requirements, and payment standards that vary considerably depending on type of organizations and the services they provide. To achieve this requires promoting not only compliance with rules, but ethical conduct and a culture that promotes prevention, detection, and resolution of conduct that does not conform to the established rules.
  2. Health care compliance can also be defined also as the ongoing process of meeting, or exceeding the legal, ethical, and professional standards applicable to a particular health care organization or provider. The HSS Office of Inspector General (OIG) has helped with the definition of health care compliance through its compliance guidance documents, which call for compliance efforts to be designed to establish a culture within organizations that promotes prevention, detection, and resolution of instances of conduct that do not conform to federal and state law; federal, state, and private payor health care program requirements; and ethical and business policies. The scope extends to many areas including patient care, billing, reimbursement, managed care contracting, research standards, Occupational Safety and Health Administration (OSHA) standards, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards, and the Health Insurance Portability and Accountability Act (HIPAA) privacy and security rules, to name a few. The biggest challenge for health care organizations and their compliance officers is keeping track of all these numerous requirements and regulations.

Meeting the definition for health care compliance means meeting all of the rules and requirements set forth and applicable to them across a broad range of criteria, including all applicable legal, regulatory, program requirements, and payment standards that vary considerably depending on type of organizations and the services they provide.  As one examines the meaning of health care compliance, it becomes clear that it embraces a great variety of things, including adhering to laws, rules, regulations, and program requirements, as well as organization Codes of Conduct, policies, and procedures governing the day to day operations. Because health care has become so complex in recent years, the industry is under constant scrutiny. Compliance programs promote not only compliance to rules, but to ethical conduct and the promotion of a culture that encourages prevention, detection, and resolution of conduct that does not conform to federal and state law; federal, state, and private payor health care program requirements; and the organization’s ethical and business policies. It is nearly impossible to define the extent or complexity of the ever changing healthcare compliance world. New laws and regulations come into play on a daily basis from all level of government.  Some of these have far ranging implications such as HIPAA and HITECH laws that are designed to protect the privacy of patient information.

 

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 Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2018 Strategic Management Services, LLC. Published with permission.