Transcript Fraud & Abuse in Healthcare

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FRAUD AND ABUSE:
WHAT DOES IT HAVE
TO DO WITH ME?
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Headlines…
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Fraud accounts for 19 percent of the $600
billion to $800 billion in waste in the U.S.
healthcare system annually.
Investigators recovered a record-breaking $4.1
billion in health care fraud money during 2011
OIG reports $3.0 billion in fraud and abuse
recoveries in 2010 Semi-annual Report to
Congress
Hospice Headlines…
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False Claims Act:
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July 2012: Altus Healthcare and Hospice, Atlanta, GA:
$555,572 settlement. Falsely submitted claims for inpatient
hospice services.
March 2012: Five nurses, Philadelphia hospice, indicted for
conspiring to defraud Medicare of millions of dollars.
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“allegedly authorized and supervised the admission of inappropriate
and ineligible patients for hospice services, resulting in approximately
$9.32 million in fraudulent claims“
The creation of false documents related to services for about 150
patients
Nursing supervisor penalty: Could be sentenced to 108 to 135 months
in prison, a fine of up to $150,000, and a $1,400 special assessment.
Other nurses: Possible prison terms ranging from 21 to 33 months,
and fines from $50,000 to $60,000.
Other Impact on Hospices?
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More scrutiny
Identification of aberrant behavior among hospice
providers – comparing providers in state, MAC,
CMS region
Targets
 Long
and very long stays
 Particular diagnoses – debility, Alzheimer’s, AFTT,
COPD
 GIP length of stay greater than 5 days or 7 days
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Audits for Fraud and Abuse in Hospice
Types of Contractors
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Contractors reviewing hospice claims:
(not all-inclusive)
 MAC
– ADR process
 Recovery Audit Contractors (RAC)
 Medicaid Integrity Contractors (MIC)
 Medicaid Recovery Audit Contractors
 Zone Program Integrity Contractors (ZPIC)
 Office of Inspector General (OIG)
 Department of Justice (DOJ)
New Levels of Scrutiny
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DOJ
OIG
Legal
Oversight
OVERSIGHT
ZPIC/PSC
MIC
Compliance
Oversight
FI/Carrier/MAC
RAC
Routine
Business
QIO
CERT
RISK
Source: Strafford Publishing
Hospice Activity
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RAC
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Not hospice specific but
connected to hospice
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DME claims when patient is
hospice patient
Part B billing when patient is
hospice patient
Condition Code 07 when patient
is hospice patient – inpatient
and outpatient
Hospice related services –
inpatient and outpatient
Required to have CMS
approval before
commencing
MIC Audits
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several states
ZPIC
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Active in 38 states
Whistleblower cases
Data mining/On-site visits
No CMS approval required
Extrapolation possible -- %
of claims applied to universe
of claims
ZPIC Contractors
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ZPIC
Zone
States
Safeguard Services (SGS)
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California & Nevada
AdvanceMed
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Washington, Oregon, Idaho, Utah, Arizona, Wyoming,
Montana, North Dakota, South Dakota, Nebraska,
Kansas, Iowa, Missouri, Alaska
Cahaba Safeguard
Services
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Minnesota, Wisconsin, Illinois, Indiana, Michigan, Ohio,
Kentucky
Health Integrity
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Colorado, New Mexico, Texas and Oklahoma
AdvanceMed
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Arkansas, Louisiana, Mississippi, Tennessee, Alabama,
Georgia, South Carolina, Virginia, West Virginia
Under Protest
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Pennsylvania, New York, Delaware, Maryland, D.C., New
Jersey, Massachusetts, New Hampshire, Vermont, Maine,
Rhode Island, Connecticut
Safeguard Services (SGS)
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Florida
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Why Should We Care?
Impacts on Your Hospice
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Claims payment for patient care may stop
Could impact staffing, salaries, hospice operations
Patient care practices may be in question
Your hospice’s claims data will be compared to others in
your state, your MAC region and the country
Focus areas include:
Level of care – review of GIP
 Length of stay
 Certain diagnoses – dementia, debility, COPD
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Documentation is the key
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Clinical staff documentation
Preparation of bills
 Pre
submission review
 Checklist for signatures, dates, completion
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New regulatory requirements in place?
 Brief
physician narrative
 Face-to-face encounter
 Compliance plan
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Keys for Clinical Staff
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Thought for the Day
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Fast is fine, but accuracy is
everything.
Wyatt Earp
Effects of Documentation
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Descriptive,
consistent
documentation
Good survey
outcomes
Compliant, reputable,
successful hospice that
delivers quality patient
care at EOL
Defensible
claims
Effects of Documentation
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Vague,
inconsistent,
documentation
marginal survey
outcomes
Compliance issues, cash
flow issues even if
hospice delivers good
patient care
More difficult to
defend claims
Important Aspects of Hospice
Documentation
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Patient’s condition
Status of the family or caregiver
The environment of care
Description of care/services provided
The patient’s pain & symptom presentation and
associated interventions and evaluations
Communication with the physician and other team
members
The observed or verbal patient/family response(s)
to interventions and care
Other important aspects of documentation
Documentation
should be legible
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Documentation: Accuracy
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Rectal exam revealed a normal size thyroid
She stated that she had been constipated for most of her life until
1989 when she got a divorce
I saw your patient today, who is still under our car for physical
therapy
She is numb from her toes down
The patient suffers from occasional, constant, infrequent
headaches
Patient was alert and unresponsive
When she fainted, her eyes rolled around the room
Patient has chest pain if she lies on her left side for over a year
Documentation: Accuracy
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On the second day the knee was better and on the third day
it had completely disappeared
The patient is tearful and crying constantly. She also appears
to be depressed
Discharge status: Alive but without permission
The patient refused an autopsy
The patient expired on the floor uneventfully
Patient has left his white blood cells at another hospital
The patient's past medical history has been remarkably
insignificant, with only a forty-pound weight gain in the past
three days
Other Important Aspects of Documentation
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Documentation should be:
 Objective
 Concise
(more is not always better)
 Authentic
 Timely
 Comprehensive, but pertinent
 Consistent
 Tell the patient’s/family’s story
Nurse and Psycho-social Documentation
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Nurses’ documentation painted the clinical picture of
eligibility
Psycho-social documentation did not match
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Example:
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 Patient
with dementia, the nurse’s note indicated a FAST
score of 7d while the social worker documented that
the “patient was in the activity room putting together a
puzzle upon arrival.”
Two-fold strategy to improve
compliance
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Change documentation format to prompt
psychosocial staff to write their observations
relating to the patient’s hospice eligibility within the
scope of their practice
The second was to provide education on the signs
and symptoms of physical decline related to
specific disease types which they should look for
Examples of Documentation
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Correct Note:
Incorrect Note:
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Patient smiled and greeted
chaplain upon arrival into
patient’s room.
Talked about her husband and
family members while holding
chaplain’s hand.
Chaplain provided a ministry of
presence, prayed with patient,
and provided a follow-up phone
call to the daughter.
Patient denied pain and
appeared comfortable.
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Data: Patient was received in her wheelchair,
leaning to her left side with support pillows as
aide was completing feeding her lunch. Patient
was coughing after eating and stared into
space. Care plans being addressed: altered
mental status; spiritual presence needs.
Action: Chaplain greeted patient, held her
hand, encouraged eye contact, read scriptures
and prayed with patient.
Results: When chaplain brought up husband’s
name, patient began to talk about him as if he
were still alive, although he has been deceased
for years. Patient appeared comforted by
prayers and scripture reading as evidenced by
calm affect and closed eyes.
Observations: Patient coughed after mealtime,
leaned to side, and was unable to engage in
reality-based conversation.
Plan: Chaplain will visit patient in two weeks to
provide spiritual presence and will phone
patient’s daughter to offer support for
anticipatory grief.
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Keys for Managers and Leadership
Focus for Staff Leadership
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Know the regulations
Develop AND follow protocols to give maximum
time to respond to ADRs and medical record
requests
Hire excellent clinicians
Review documentation regularly
 Completeness
 Accuracy
 Objectivity
Scrutiny You Can Avoid
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Physician signatures appear on cert and recert
forms
Dates filled in with physician signatures
Notice of Election has required components
Certification and recertification forms meet
regulatory requirements
All components of certification present
 Attestation
when face-to-face encounter conducted
 Physician narrative written and signed
The Physician Narrative
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Components of a comprehensive and adequate
physician narrative should include:
 Explanation
of the clinical findings that supports a life
expectancy of 6 months or less
 Reference to specific LCDs as appropriate
 Reference to prognostic indicators or symptom
management scales as appropriate
 Reference to functional status using recognized tools
(PPS, ECOG, Karnofsky, FAST, NYHA)
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The Physician Narrative
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Components of a comprehensive and adequate
physician narrative should include:
 Specifics
of the patient’s condition – the most
important thing
 Evidence of a decrease in anthropomorphic
measurements
 Recent hospitalizations or ED visits
 Information about other significant complications in
addition to the LCD-specific criteria appropriate for
that particular diagnosis
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Certification: Form Content
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Six months or less prognosis statement – if the
terminal illness runs its normal course
Benefit period dates to which the certification or
recertification applies
Signature and date by the physician(s) – no stamps
Physician narrative
Physician narrative attestation
Face-to-face encounter date
Face-to-face encounter attestation
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Notice of Election Form
Content – The election statement must include five
elements:
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Identification of the particular hospice that will
provide care to the individual
The individual's or representative's acknowledgement
that he or she has been given a full understanding of
the palliative rather than curative nature of hospice
care, as it relates to the individual's terminal illness
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Notice of Election Form (Cont.)
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Acknowledgement that certain Medicare services, as
set forth in paragraph (d) of this section, are waived
by the election
The effective date of the election, which may be the
first day of hospice care or a later date, but may be
no earlier than the date of the election statement
The signature of the individual or representative
Verbal election is not acceptable
Cannot be backdated
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Protocols for Audits and Record Review
Front desk
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If an auditor arrives in person?
Ask for identification
 Is the company listed on the state specific list of auditors?
 Chain of command
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Plan in place
Do you know who they are?
 Want a conference room? Away from patient care teams…
 Access to medical records
 Response time for copying
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Mail Room
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Mail/ fax comes into hospice organization
 Locate
sender information
 Consults state specific auditor list for company name
 If located, staff delivers letter/fax to administrator or
 Company name not located on auditor list – staff
member processes mail/ fax per hospice’s policy
 Chain of command
Staff member interviews
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Auditors may request to interview clinical staff
Why?
How should staff prepare?
What are auditors looking for?
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OIG – Work Plan and Recent Reports
FY2013 OIG Work Plan
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Acute-Care Hospital Inpatient Transfers to Inpatient
Hospice Care
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Hospice Marketing Practices and Financial
Relationships with Nursing Facilities
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Review Medicare claims for inpatient stays when beneficiary
was transferred to hospice care and examine the relationship
between the acute-care hospital and the hospice provider.
Review hospices’ marketing materials and practices and their
financial relationships with nursing facilities.
Medicare Hospice General Inpatient Care
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Use of GIP from 2005 to 2010. Assess appropriateness of GIP
claims and beneficiary drug claims billed under Part D.
FY2013 OIG Work Plan
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Medicaid: Hospice Services: Compliance With
Reimbursement Requirements
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will determine whether Medicaid payments for
hospice services complied with Federal reimbursement
requirements.
OIG Report Issued on Part D and Hospice
Summary of Findings
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Calendar year 2009
Prescription analgesic, anti-nausea,
laxative, and anti-anxiety drugs
Prescription drugs used to treat COPD
and ALS
Covered under the hospice per diem.
Medicare program could be paying
twice for prescription drugs for
hospice beneficiaries: once under the
Medicare Part A hospice per diem
payments and again under Medicare
Part D.
Hospice beneficiaries could also be
unnecessarily paying copayments for
prescription drugs under Part D.
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198,543 hospice beneficiaries
677,022 prescription drugs through
Medicare Part D
Part D paid pharmacies
$33,638,137 for these prescription
drugs
Beneficiaries paid $3,835,557 in
copayments
Published July 3, 2012
A-06-10-00059
What this report means for hospices
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Part D pharmacies may be billing hospices for
drugs that could/should be related
Other auditors may also be reviewing “related”
prescription drugs
There may be requests for payment for the copays paid by the beneficiary
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What a hospice should do
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Complete a comprehensive assessment of the patient’s
medications
Clearly document in the clinical record which medications
will be covered under hospice
Pay for the drugs related to the terminal illness, i.e. inhaler
for COPD
Discuss which medications will not be covered by the
hospice and why with the patient/ family
Complete an assessment of patients residing in a nursing
facility to ensure that pharmacy providers are not billing
hospice related medications to another payer once a
patient has elected to receive hospice
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Developing a Compliance Plan
Compliance plans
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Vigilance is required about compliance activities
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Compliance with:
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Medicare Hospice Conditions of Participation
Other hospice regulations
Claims submission requirements
Eligibility requirements
Requirements for continued eligibility
Compliance plan should include:
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Specific timeframes for internal audits of agency practices
Protocol for reviewing processes that may be out of
compliance with current laws and regulations.
OIG Compliance Guidance
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Published in 1999
Still valid today
28 areas of risk
Find complete list at:
www.nhpco.org/regulatory/fraud and abuse
Risk areas for hospice fraud and abuse
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Eligibility
 Does
this patient meet the eligibility requirements for
admission to the hospice program?
 Does the documentation support eligibility?
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Site of care
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the patients in nursing facilities meet the eligibility
requirements for hospice?
 Is the length of stay appropriate, or were those
patients admitted “too early” for hospice care?
Risk areas for
hospice fraud and abuse
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Level of care
 Does
the level of care match the patient’s symptom
management concerns or family need for respite?
 Is General Inpatient care appropriate and documented
in the medical record?
 Is GIP evaluated every day?
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Claims submission
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the dates of service, Q-codes for location of care,
and levels of care accurate?
 Do forms have necessary signatures and dates?
Contacts for Reporting Fraud
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Beneficiaries:
 Call 1-800-MEDICARE or
 DHHS OIG hotline at 1-800-HHS-TIPS
(1-800-447-8477)
Providers:
 Call the DHHS Office of Inspector General hotline
at 1-800-HHS-TIPS (1-800-447-8477).
NEW Regulatory and Compliance Center
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www.nhpco.org/regulatory
NEW Regulatory and
Compliance Center Buttons
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Q&A
NHPCO members enjoy unlimited access to Regulatory Assistance
Feel free to email questions to [email protected]
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Regulatory and Compliance Team
at NHPCO
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Jennifer Kennedy, MA, BSN, RN
Director, Compliance and Regulatory Affairs
Judi Lund Person, MPH
Vice President, Compliance and Regulatory
Leadership
Email us at: [email protected]