Corporate Compliance Eugenia Smither, RN, BS, CHC Corporate Compliance Officer Vice President of Compliance and Quality Improvement.

Corporate Compliance

Eugenia Smither, RN, BS, CHCCorporate 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

FRAUD – “Intentional deception

or misrepresentation which an individual or entity makes, knowing it to be false & that the deception could result in some unauthorized benefit.”

ABUSE – “Any incident or

practice inconsistent with accepted & sound medical, business, or fiscal practices which directly or indirectly results in unnecessary costs to the benefit program.”

Why have a

Compliance Program ? Helps identify intentional criminal &

unethical conductHelps identify weaknesses in internal

systems & management structuresEncourages staff to report concerns

internally, rather than externallyAllows 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 & RegulationsAdministrative Sanction & ExclusionAnti-Kickback Statute Antitrust LawsBalanced Budget ActDeficit Reduction ActFalse Claims ActFraud and Abuse Statutes/Illegal

Remuneration StatutesMedicare Conditions of Participation

STATE LEVEL

Dept. of Aging

State Medicaid

REGIONAL LEVELUS Congress

Health &Environment

Cahaba GBA(FI)

Cigna(MAC)

Palmetto (MAC)

Hospice

FEDERAL LEVEL

US GovernmentAccountability Office

(GAO)

Medicare PaymentAdvisory Commission

(MedPAC)

Office ofInspector General

(OIG)

US Dept. of Health &Human Services

(DHHS)

Office of Ass’t Secretary for Planning & Evaluation

(ASPE)

Centers for Medicare &Medicaid Services

(CMS)

Conditions of Participation (CoPs)42 CFR Part 418

Medicare AdministrativeContractors

(MACs)

CMS Regional

National Hospice & Palliative CareOrganization

(NHPCO)Hospice & Palliative Care

State Organizations

Environmental Forces Impacting Hospice Agencies

Zone Program Integrity Contractors(ZPICS)

Medicaid Integrity Contractors(MICS)

Payment Error Rate Measurement(PERMS)

Comprehensive Error Rate Testing(CERTS)

Health Care Fraud Prevention & Enforcement Action Team

(HEAT)

Recovery Audit Contractors(RACS)

NGSFI

NHIC (MAC)

Surveyors

©Harry Hynes Memorial Hospice,

2011

Oversight by Compliance & Legal as records are submitted

CERT

QIORoutine Business

FI/Carrier/MAC

MIC

RAC

ZPIC/PSC

OIG

DOJ

Compliance Oversight

Legal Oversight

RISKSource: Strafford Publishing

OVE

RSIG

HT

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 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 2006Detect 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 riskSimilar 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.justice.govwww.hhs.gov www.stopmedicarefraud.gov

Zone Program Integrity Contractors(ZPICs)

In 2008, consolidated PSC (Program Safeguard Contractor) with MEDIC (Medicare Drug Integrity Contractor) to form ZPICs– 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 ActivitiesPolicy and ProceduresEmployee 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 requirementsHOB’s commitment to comply with federal, state,

and private insurer standards & our partnersOutlines leadership responsibilitiesDirects us in response to inappropriate/unlawful

behaviorAddresses disruptive behavior and

organizational responseDefines Environmental CompliancePolitical activitiesMarketing practices

Compliance PlanLists how we address the “Seven Elements” of an

effective compliance program Work plan is developed based on our risksLists the OIG Risk Areas, Applicable Laws and

Regulations Supported by HOB policies

Address regulatory complianceAddress accreditation processFinancial reporting and records (internal controls)Business courtesies (receiving, extending)Outlines handling of business information/systemsAntitrust, 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-HHS-TIPS)

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 documentsEngagement of legal counsel, auditors or

other health care expertsSubsequent review for similar problems

Reporting to Authorities Have a duty to report when requiredFederal 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 impactReport 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 warningWritten warningWritten reprimandSuspensionTerminationRestitution

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.