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 13^th, 19^th 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.

Introduction to Decade’s Hottest Topic

by Ed Buckley 
with Tim Rowan

Lost revenue and poor compliance go hand in hand. They infiltrate a home health care agency together. 
Managing revenue cycle means improving compliance as much as it means ensuring complete and accurate billing processes and A/R follow up procedures. 

Compliance is the responsibility of all staff, especially those with clinical and financial responsibilities. In today’s Medicare environment — and it is not much different if a provider’s primary payer is insurance or the patient — mere automation is insufficient. Quality Revenue Cycle Management (RCM) processes are required today more than ever.

In fact, RCM is the number one key to meeting today’s home health compliance challenges. Considering the current regulatory environment, where we are seeing sharp increases in ADRs, the imminent rise of collection agencies such as Recovery Audit Contractors, and intensive, relentless MAC, MIC and Z-PIC audits, home healthcare processes and systems dare not fall short of the challenge.

RCM processes must build in compliance, not treat it as an afterthought or a luxury. Patient care is a complex proposition. Building in compliance requires that communication and interdisciplinary coordination are part of a plan of care that manages a patient’s medical needs. There are four key components to the process of building compliance into a plan of care:

• technology
• documentation
• coding
• billing

These four business pillars support RCM and form a foundation for compliance. Think of RCM as permeating the entire life cycle of a patient care episode, from referral to assessment to plan of care to patient record and finally to the revenue derived from that care. When a plan of care is carefully developed and managed through compliant systems and processes that all talk to each other, a complete management cycle results. When done right, the benefit of this cycle is that it provides the agency with a comprehensive, dynamic, profitable, accurate and compliant home healthcare business.

Most importantly, it results in the ability to provide the highest possible level of patient care, making the agency the first choice among doctors, hospitals and care planners.

Technology only part of the answer

In order to achieve compliance in the contemporary regulatory environment, home healthcare providers must employ more than just point-of-care technology and a centralized billing/coding system. It is imperative to utilize the RCM processes in order to verify assessments, review clinical processes and reconcile resulting data as part of compliant revenue generation. Incorporating RCM processes as part of an overall business strategy often results in improved reimbursement, bullet-proof billing compliance and stellar clinical outcomes.

Lost revenue and poor compliance go hand in hand because OASIS and coding errors are often the result of incomplete and incongruent assessments. Billing mistakes typically occur because visit activities vary from physician orders. Data errors are frequently triggered by hurried keying into point-of-care and EMR systems. A well-developed RCM system as part of operations, implemented in real time, can mitigate most of these costly mistakes. 

With compliance comes control and peace of mind. Compliance leads to more positive patient outcomes, fewer hospital readmissions, more retained revenue, greater efficiency and more predictable cash flow, while providing the business peace of mind that comes only when patient outcomes match plans of care. A home health agency’s business depends on the quality of patient care provided. Doctors, hospitals, and care planners need an agency they can trust to deliver quality care and outcomes, period. 

RCM begins with a complete data capture and error mitigation philosophy impacting every staff member and virtually every aspect of a healthcare provider’s business operations. This includes:

• accurate patient assessments, the cornerstone
• correct OASIS documentation
• clean patient data
• physician order monitoring
• visit reconciliation
• clinical coding with review
• QI oversight
• A/R management and collections follow-up

Systems must be designed into processes that identify errors prior to revenue generation. Catching up with after-the-fact chart audits is no longer an adequate process in today’s environment. Operations must have built-in processes that catch incongruence in real time while it is occurring…not after the bill has flown out the door. RCM systems monitor all administrative and clinical components that contribute to the capture, management and collection of patient service data.

The heart of the RCM process is a team of specialists charged with the responsibility of establishing and implementing policies, procedures, and performance measures and standards.

What RCM is and is not

RCM begins and ends with clinicians 
In order to obtain compliance within the RCM process, coding accuracy is indispensable. For the average home healthcare agency, however, achieving the necessary level of accuracy on a consistent basis is often an impossible dream. Among the most prominent roadblocks to coding success is the speed with which codes change. Dozens of alterations take place each year, seemingly in the blink of an eye. In 2009 alone, a total of 290 new codes were established. 

Coding errors create even more vexing challenges, the majority of which are related to documentation accuracy and completeness. Co-morbidities are missed during this phase, opening the floodgates to improper sequencing and inaccurate primary diagnoses. Clearly, RCM must begin with management’s confidence that assessments are accurate. Crucial to this phase are clinical tools. It is management’s responsibility to assemble the tools — especially comprehensive and ongoing training programs — that will properly channel the critical thinking skills required and expected of field staff.

Then, even with confidence in your staff’s coding and documentation skills, ensure excellence by assigning RN coding experts to review every assessment to see that every plan of care reflects best use of ever-changing codes and regulations. 

Accurate and compliant coding is not only the image of your standard of care that you broadcast to the community. It is the cornerstone of your ability to receive and retain revenue. Getting it right is the best way to grow your business and increase patient and doctor satisfaction with your plans of care. 

Cliché though it may be, there is a bottom line to consider here. Management’s focus on strong patient outcomes through compliance means greater revenue retention and the lowest audit risk. Clearly, effective RCM is a timely solution providing agencies with a foundation for a vigorous bottom line, a solid grip on financial activities, freedom to focus on priorities, and a welcome relief from compliance anxiety.

Ed Buckley is CEO of Select Data, a home care software and clinical services company based in Anaheim, California. He welcomes comments and can be reached at ed.buckley@selectdata.com