Archive for August, 2011

The Corporate Compliance Program in Healthcare

Tuesday, August 30th, 2011

The government is escalating investigations through Recovery Audit Contractors (RACs), Medicare Administrative Contractors (MACs), Medicaid Integrity Contractors (MICs),  Zone Program Integrity Contractors (Z-PICs), and now, the Health Care Fraud Prevention and Enforcement Action Team (HEAT).  Home Health agencies are at a critical crossroads.  It is essential that agencies take control, review processes, and proactively identify and address vulnerable areas.

The MACs are looking at current claims filed. The RACs have taken a retrospective look at claims, but it has been the Z-PICs who have been busy. They are the auditors using refined algorithms to identify risk patterns.

The RAC auditors have been authorized to recover “improper payments “of preapproved areas of risk.  In the demonstration project, high areas of risk included incorrectly coded records, therapy appropriateness, and medically unnecessary services. The industry has concerns that therapy 13th, 19th visit and 30 day assessments will be a prime target. What about the Face–to-Face encounter?  RACs are expected to be busy, busy, busy when probing compliance with that regulation.

The HSS and the U.S. Department of Justice have teamed up to create the new Health Care Fraud Prevention and Enforcement Action Team (HEAT) to investigate and work to eliminate fraud in healthcare. They are using predictive modeling algorithms and high level technology as key tools for their mission. Their initial focus  has been directed toward Durable Medical Equipment, as well as services paid for by Medicare Part C (Medicare Advantage) and Part D (Prescription Drug Programs).

Now, more than ever a strong Corporate Compliance Program is essential in the industry.

Agencies should be auditing samples of past claims, reviewing present processes, educating personnel, and updating their present Corporate Compliance Plan. The OIG believes that effective compliance programs should include the following components, which are based on the seven steps of the Federal Sentencing Guidelines.

Components of a Compliance Plan:

  1. Compliance Policies and Procedures to include written standards of conduct
  1. Designation of a Compliance Officer and Compliance Committee
  2. Ongoing Education and Training
  3. Effective lines of communication; Process for Reporting Concerns, such as a hotline
  1. Enforcement of Standards
  2. Development of an Auditing and Monitoring System
  3. Corrective Action Process for Correcting Compliance Problems

The Corporate Compliance Plan should represent the corporate wide initiative designed to detect and prevent problems of noncompliance and include:

  • An Introduction and Purpose complete with expectations.
  • Directives
    • Key Personnel
    • Standards
    • Reporting
    • Confidentiality
    • Response and Corrective Action
    • Enforcement and Discipline
    • Ø Standardized Conduct
    • Standards for Business Conduct
    • Code of Conduct

Code of Ethics

  • Employee Open Communication
    • Agreement with the National Hotline Service
    • Tracking all calls including interventions

Effective programs have strong internal controls to promote adherence to applicable federal and state laws. They will also include internal auditing components of agency processes, services, and products with feedback mechanisms. There is a well defined agency code of conduct with a compliant culture and frequent employee training.  An infrastructure includes a Corporate Compliance Officer who, in addition to other duties, will monitor industry areas audit focus. The agency can then explore their vulnerabilities.

The OIG Top Medicare PPS Compliance Issues include:

  • Reporting additional visits not made in order to exceed LUPA and therapy thresholds
  • Providing additional visits to avoid LUPA and therapy thresholds
  • Upcoding  and downcoding on the OASIS
  • Duplicate bills and timeliness
  • Returning credit balances promptly
  • Routine waivers of copays
  • Billing for services without physician orders

The RAC Demonstration Project issues include:

  • Incorrectly coded 35%
  • Lack of Medical Necessity 40%
  • Insufficient documentation 10%

What are your audits reflecting? Is documentation adequate to support all diagnoses? Does the documentation support the skill necessary for each visit?

Besides the above areas that might include potential claims fraud and quality of care false claims (False Claims Act 31 U.S.C. 3730), home health Corporate Compliance Officers must also  be aware of HIPAA compliance, Patient Freedom of Choice 1802, Conditions of Participation (COP) and licensure violations as well as monitoring referrals to prevent referral kickback violations (Stark II, Phase III, SSA 1877) and Civil Monetary Penalties, SSA 1128(a)(5).

Home health agency compliance officers should expect to remain on the frontline of risk assessment and enforcement of health care regulations. The RACs are only beginning their audits.

A positive by-product of an organization that effectively implements a Corporate Compliance Plan is the emergence of a renewed vision of the future. In this age of government audits, a forward thinking organization will create or update their program for all of the right reasons. However, corporations will soon realize that they can leverage their compliance programs as public relations tools, which not only affirm their role as solid community citizens, but, also as business associates who share commitment to integrity and ethics.

This week Select Data has provided a sample Corporate Compliance Power Point Presentation for your use. This can be used as a solid shell to have specifics of your organization added. It reinforces the basics. There is no such thing as no need for reinforcement in compliance, especially not in this climate.

To download a copy of this PowerPoint click here.

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Hospice Face-to-Face Encounter Requirement

Thursday, August 25th, 2011

This hospice encounter, like the home health face-to-face encounter, is causing concern among the industry. Agencies view it as yet another burden. Below we break down the regulation and look at “Who” may perform the face-to-face encounter, “What” all is required, and “When” must it take place.

“Who” may certify the face-to-face encounter?

Effective January 1, 2011, in response to the Patient Protection and Affordability Act, CMS added a “face-to-face encounter” requirement to the hospice certification requirements. The rule requires that hospice patients have a face-to-face encounter with a hospice physician or hospice nurse practitioner. The rule requires the same physician who has the encounter to certify the patient’s terminal illness.

Some flexibility has been added in the new final wage index published July 29, taking effect October 1, 2011. The face-to- face encounter will indeed become more flexible and will “allow any hospice physician to perform the face-to-face encounter regardless of whether that same physician recertifies the physician’s terminal illness and composes the recertification narrative.” (www.ofr.gov/OFRUpload/OFRData/2011-19488_PI.pdf).

A hospice physician is one who is employed by the hospice or contracts to perform work for the hospice. The hospice nurse practitioner must be employed by the hospice.

In the final rule of July 29, 2011, effective October 1, 2011, CMS rejected the request by the National Hospice and Palliative Care Organizations (NHPCO) to include physician assistants and clinical nurse specialists to perform the Face-to-Face encounter. The approved list continues to only include hospice physicians and nurse practitioners.

CMS did clarify that “hospice employee” does include employees of an organization which owns a hospice. There had been much confusion regarding whether health systems that employed nurse practitioners and owned a hospice  could have those practitioners perform the face-to-face encounters.

“What” additionally may be necessary?

Once the physician or nurse practitioner conducts the face-to-face encounter, they attest to the date of the encounter, and sign the attestation clause.

Since 2009, the physician must also document a narrative of clinical findings supporting life expectancy of six months or less.

With the new face-to-face encounter requirement, physicians must now include a narrative for the third beneficiary period and each subsequent benefit period. The narrative must delineate clinical findings with the face-to-face encounter that supports the life expectancy of six months or less.

The physician signature is required immediately below the narrative if it is a part of the certification form. If the narrative is a part of the addendum to the certification form, the addendum must also be signed by the physician.

“When” must the face-to-face encounter take place?

The face-to-face encounter must take place no more than 30 days prior to the patient’s third benefit period AND every subsequent benefit period thereafter. In the Open Door Forum on March 2, 2011, CMS was very clear that they expect a face-to-face encounter to be completed prior to the start of the third benefit period. However, CMS recently issued CR7337 to include exceptional circumstances for this requirement. In cases where a hospice newly admits a patient who is in the third or later benefit period exceptional circumstances may prevent a face-to-face encounter from being conducted prior to the start of thebenefit period. In this circumstance, a face-to-face which occurs within 2 days after admission will be considered timely. If the patient would die within 2 days of admission without a face-to-face encounter, the encounter requirement would be considered complete.

In the March 2, 2011 Open Door Forum, CMS was most direct in stating that the exception is meant for the last minute admission, weekend admissions, and other exceptional circumstances.

The new Rule effective October 1, 2011

CMS is seeking public reporting of quality data from hospice agencies. Public Reporting will begin with two indicators: 1) the percentage of patients whose pain was brought to a comfortable threshold within 48 hours of hospice admission and 2) a structural measure indicating the hospice has a quality assessment and performance improvement (QAPI) program.

Data collection will become mandatory CY2012 with data submission required by January 2013 for the structural measure and April 2013 for the quality measure. Hospices that do not submit quality data should expect the market-based update for 2014 reduced by two percentage points.

Data reporting is expected to increase with additional quality indicators. Most hospice leaders will not find this surprising.

Note that after the release of the CY2011 and the face-to-face encounter, CMS stated, “we will issue instructions to the contractors who perform medical reviews to ensure compliance with this regulation.” The Z-PICs, PSCs, and RACs are expected to be more active within the Hospice industry. Compliance plans not yet mandated have become expected and essential. Tracking the signed face-to-face encounter is a requirement for payment; another essential element for the billing review.

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Posted in CMS, Face to Face Encounters, Home Health, Legislation, Psychiatric | No Comments »

P.O.L.S.T. Physician Orders for Life-Sustaining Treatment

Monday, August 8th, 2011

Select Data serves home health and hospice agencies throughout the country and the Virgin Islands. One agency, not from a POLST state recently asked that we write an article on POLST as they had seen the abbreviation on the Select Data SmartScribe forms. Their state is considering a move toward the Physician Orders for Life-Sustaining Treatment Paradigm program.

The POLST program is designed to improve the quality of care received by individuals at the end of life. It is designed to effectively communicate patient wishes through physician orders on a highly colored form (usually PINK) so as not to be missed by health care professionals.

What is the Difference Between POLST and Advance Directives?

POLST is a document that clearly states a patient’s end of life wishes and includes physician orders and patient signature. Advance Directives generally contain information about a person’s desire to be mechanically ventilated, artificially fed, and comfort measures. Advance Directives will not actively protect against unwanted emergency care, resuscitation specifics, or a transfer to an acute care setting. POLST includes CPR wishes, artificial nutrition choices, and specific statements identifying if a transfer to a hospital is desired. POLST has physician orders to back up the patient’s wishes.

History of the POLST Paradigm Initiative

Despite advance directives, medical ethics leaders recognized that patient wishes for life-sustaining treatments were not consistently being honored. In 1991, in Oregon, the POLST Paradigm Initiative was begun.  The Medical Treatment Coversheet, designed to transport portable medical orders based upon the patient’s wishes emerged from the Initiative lead by The Center for Ethics in Health Care at Oregon Health and Science University. With stakeholders from several health care organizations, the Center coordinated the training of health care professionals regarding use of the form.

In 1995, the name of the Initiative was changed to Physician Orders for Life-Sustaining Treatment and the form was released for full use in Oregon. As the program satisfaction grew, other states sought legislation to initiate the program. West Virginia and New York were forerunners in program adoption and they lead the way in learning to integrate the new program within state specific laws.

Presently,(per www.obsu.edu/polst ), the Medical Treatment Coversheet is used by over 95% of nursing homes in Oregon and used by all hospices. It is considered “the accepted medical standard of care.” Together, with Oregon members, program leaders of New York, Pennsylvania, West Virginia, and Wisconsin joined together forming the original National POLST Paradigm Initiative Task Force. That Task Force has been instrumental in driving POLST Program development in California, Washington, Idaho, Colorado, Tennessee, and Virginia with several other states, such as Texas, Florida, Georgia, Indiana, Alaska, and Ohio actively developing programs.

The National POLST Paradigm Task Force (NPPTF): Program Requirements

The Task Force developed the description of the program with specific program requirements. The Program Structure requires an “effective statewide or regional coalition” working on a strategy to establish statewide implementation.

The Program requires a set of medical orders on the Medical Treatment Coversheet. There must be ongoing training of health care professionals at all levels, that includes an understanding of the POLST Program, its goals, use of the Form, as well as understanding “how to conduct a POLST conversation.” (www.obsu.edu/polst)

The Medical Treatment Coversheet includes physician signature. The patient signature is encouraged to be on the completed form as well which includes informed consent and shared medical decision making. The program requires a mechanism for ongoing evaluation and its processes. In addition, there must be a single “strong entity” within the state or region that accepts responsibility and ownership for the Program.

The Form and it’s Requirements

Treatment provided requires a specific medical order based upon the patient’s goals of care and their preferences. POLST offers three choices. First, Comfort Measures Only means care that would relieve pain and suffering. The medical orders “explicitly state in the medical orders that comfort measures are always provided.” (www.polst.com ) The patient is to be transferred if “comfort needs” cannot be provided. Second, the choice is “Limited Additional Interventions” that offer comfort measures as well as IV fluids and antibiotics. This option includes a choice to be transferred to an acute care setting only if suffering could not be relieved at home. The third choice is that of “Full Treatment” and includes the Comfort Measures, IV Fluids and antibiotic interventions as well as CPR and intensive care if needed. The orders must be signed and dated.

To protect the patient’s wishes PRIOR to emergency intervention, requires POLST. For more information regarding this subject, go to www.POLST.com or www.ohsu.edu/polst

The Form must provide explicit direction as to resuscitation as well as patient preferences if they become pulseless or apneic. The Form must also include what the patient does NOT want including ICU, acute care, long term care, etc.

The Form must include the state of coverage. It is to be transportable so the patient may carry the Form within a state or region. The Form also clearly identifies a transfer option in case a patient’s comfort measures cannot be maintained in the present setting.

Posted in Advance Directives, Home Health, Physician Orders, POLST, Teaching/Education | 1 Comment »