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: 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.

Subscribe to the Kusserow on Compliance Newsletter

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.

Kusserow on Compliance: Preparing for compliance investigations

Most compliance officers are not professionally trained investigators and are unsure how to decide whether an issue warrants a formal investigation. Also, the great majority of issues presented to compliance officers can be resolved relatively easily without need of an investigation.  However, when situations arise warranting an investigation, it is important to know what needs to be done and how. At every step in an investigation, there are rules that must be followed regarding how things must be done—working with other internal or external parties, determining how to manage the records of investigations, and so on. It is important for anyone who may be called upon to investigate, to take time to learn some of the fundamentals of the process. The first step for any investigation is taking time to analyze all known facts upon receipt of a complaint, allegation, or information suggesting a potential wrongdoing. After this, the next step is to decide upon a course of action, such as:

  1. Closing the matter without the need of further action
  2. Having enough information to take adverse or corrective action on the issue
  3. Need to investigate to clarify issues
  4. Referring the matter to legal counsel
  5. Disclosing a violation to a duly authorized governmental authority

The following should be considered when the decision is to investigate:

  • Knowing who the deciding authority is and what they will need to make a decision
  • Development of the investigative plan
  • Establishing the scope of the investigation
  • Who is the person best qualified to conduct the investigation?
  • Whether the investigation should be under direction of legal counsel

Time is a major enemy and is a force with which to contend in any internal investigation. There is a lot involved in even a simple investigation.  It includes two key elements: documentary evidence and conducting interviews. Knowing what documents are needed is important but knowing how to properly conduct interviews requires some training and skill to produce optimum results and reduce the risks of losing valuable information and time. Writing reports of interviews and the final Investigations Report is also very important. There is both a right and wrong way to do these things.

Conducting successful compliance investigations requires professional competence and friendly persuasion, not upon the authority and power of a government agency backed by the courts. One of the most common and costly mistakes is for individual to conduct investigations without having proper training and experience. It is advisable to engage an expert to teach basic investigation fundamentals on how to: (a) conduct interviews, (b) gather evidence, and  (c) file and store documents and evidence. A few hours of training will not create a professional investigator but may provide enough guidance to ensure that proper steps are followed to avoid costly mistakes. It is also advisable to have protocols in place and in advance of being confronted with an investigation to provide guidance on how to proceed.

 

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.