Transcript The physician narrative

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HOSPICE REGULATORY
UPDATE:
THE NEW NORM
Judi Lund Person, MPH
NHPCO
© NHPCO, 2013
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Objectives
Objectives
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Sequestration
Basic hospice data
List the five most current regulatory issues facing hospices today
Describe quality reporting requirements and deadlines
Discuss the proposed quality measures and surveys discussed for
future implementation and preparation for use in 2013/2014
Identify major players in hospice audits and review and discuss the
risk areas for hospices
Describe the FY2013 Office of Inspector General Workplan for
hospice
Identify strategies to fine tune compliance plans, develop policies,
procedures and protocols to address priority risk areas
Sequestration
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What’s the latest?
New Study on Hospice
Cost Effectiveness
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Author Amy S. Kelley, MD, MSHS
Published in Health Affairs, March 2013
Findings:
 Most
common hospice enrollment periods: 1 to 7 days,
8 to 14 days, 15 to 30 days, and 53 to 105 days.
 All enrollment periods – significantly lower rates of:
 hospital
and intensive care use
 hospital readmissions
 in-hospital death
New Study on Hospice
Cost Effectiveness
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Savings for both cancer and non-cancer patients
Savings appear to grow as length of stay lengthens –
to 105 days, the end of the study period.
Investment in the Medicare Hospice Benefit translates
into savings overall for the Medicare system.
 “If
1,000 additional beneficiaries enrolled in hospice
15 to 30 days prior to death, Medicare could save
more than $6.4 million.”
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Basic Hospice Data
Patients Served by Hospice in the US 19822011
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Number of Patients
1,800,000
1,600,000
1,400,000
1,200,000
1,000,000
800,000
600,000
400,000
200,000
-
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2009
2010
2011
Number of
Patients
Source: National Hospice and Palliative Care Organization, 2012
Number of Hospices
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Number of Hospices
4000
3500
3000
2500
2000
Number of
Hospices
1500
1000
500
0
19851990199619992003200520072008200920102011
Source: Centers for Medicare and Medicaid Services, 2011 Data Compendium
Diagnoses of Hospice Patients
2011
10
Other 5.4%
HIV/AIDS, 0.3%
Stroke or
Coma 4.2%
Lung Disease
8.3%
Liver Disease
1.9%
Kidney Disease
2.4%
Heart Disease
14.3%
Dementia
13.0%
Source: National Hospice and Palliative Care Organization, 2012
Motor Neuron,
1.6%
Cancer
35.6%
Debility
Unspecified
13.0%
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Length of Service in Hospice
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80
70
Days of Care
60
67.4
69.5
69.0
67.4
69.1
50
40
30
20
21.3
20.0
21.1
10
19.7
0
Average Length of Stay
2007
2008
Source: National Hospice and Palliative Care Organization, 2012
Median Length of Stay
2009
2010
2011
19.1
Percentage of days by level of care
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Routine home care
General inpatient
Continuous home care
Respite
97.3%
2.0%
0.5%
0.2%
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Rate Cuts and Federal
Budget Challenges
Rate cuts already in place
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FY2013 Rates
Final hospital marketbasket update for
FY2013
2.6%
Less productivity reduction adjustment
-0.7%
Less additional hospice-specific productivity
adjustment
-0.3%
FY2013 rate increase
1.6%
The cap amount is set at $25,377.01 for the cap
year ending October 31, 2012
Sequestration impact, if…..
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2% reduction for services provided on or after April
1, 2013
Bill at the FY2013 rate
Contractor will apply 2% reduction with payments
Preparing your hospice for rate cuts…
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Streamline operations
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Staffing and staff caseloads
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Service area reductions
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Reduce services without affecting patient care
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Increase charitable giving
Estimated Median Profit Margin and Percent of Hospices
with Negative Profit Margins, 2010-2021
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Cutting Through the
NOISE!
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Opportunities for advocacy
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www.hospiceactionnetwork.org
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Advocacy focus for 2013
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 Vigilance
 Hill
presence
 CMS presence
 Unified message on the Hill
Never more important than this year!
HELP legislation
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Working to reintroduce in 2013:
 Expand
the list of health care professionals to conduct
the face-to-face to include:
 Physician
assistants
 Clinical nurse specialists
 Will
expand the timeframe for completion of face-toface to up to 7 days after admission
 Will require a two year pilot of payment reform
before finalizing
 Will require hospices to be surveyed every three years
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Hospice Payment Reform
Hospice Payment Reform
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ACA provision: Reform hospice payments no earlier
than FY2014
Analysis of data currently underway
CMS contractors continue to analyze
 Claims
data
 Hospice cost reports
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Technical Expert Panel continues deliberations
Analysis of what?
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Live discharges
Rate of GIP utilization and LOS at GIP
Drugs billed to Part D
 What
are the drugs?
 Who are the hospices?
 Who are the pharmacies?

Multiple diagnoses
Models
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U-shaped curve
 Higher
payments at the beginning of care
 Higher payments at the end of care
 Lower payments in the middle of care
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Other options
Goal: to align payments with cost of services
REGULATORY ISSUES AND
CONCERNS
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Eligibility
Eligibility for Admission
Medicare Hospice Benefit
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§ 418.20 Eligibility requirements.
 In order to be eligible to elect hospice care under
Medicare, an individual must be- (a) Entitled to Part A of Medicare; and
 (b)
Certified as being terminally ill in accordance with
Sec. 418.22.
Compliance “Hot Spots”
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Eligibility of hospice patients
Initial
 Ongoing
 Physician narrative
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Certain non-cancer diagnosis
Dementia/ Alzheimer's
 Debility unspecified
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Level of care documentation

GIP
MAC Compliance “Hot Spots”
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Eligibility of hospice patients
 Ongoing
 Physician

narrative
Certain non-cancer diagnosis – evidencing 6 month
or less prognosis
 Dementia/
Alzheimer's
 Debility unspecified

Level of care documentation
 GIP
– eligibility for all days billed at GIP
Opportunities to document eligibility
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Certification
Verbal certification
 Written certification
 Physician narrative statement
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Admission
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Comprehensive assessment
Ongoing hospice service
Every note by the IDT
 Update to the comprehensive assessment
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Recertification
F2F encounter
 Physician narrative statement
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Eligibility assessment
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Definitely
eligible
Probably
eligible
Not eligible
Eligibility - 1st 90-day period
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Demonstration of eligibility at admission
 Information/
consultation between attending physician
and hospice physician
 Procurement
of medical history and recent clinical
documentation
 For
the clinical record
 For use in the certification process
 Attending
physician and hospice physician certify
patient based on their medical judgment of the disease
progression
Eligibility - 1st 90-day period
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Demonstration of eligibility at admission
 Physician
narrative should concisely describe why the
patient is initially eligible for hospice
 Comprehensive
assessment documentation by IDG
should evidence the details of the patient’s eligibility
Eligibility – Continued and at
Recertification
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Demonstration of eligibility at recertification
 Physician
narrative should concisely describe why the
patient is continues to be eligible for hospice
 Clinical
note from face-to-face visit demonstrates
eligibility (if 3rd of subsequent benefit period)
 Update
to the comprehensive assessment documentation
by IDG should evidence the details of the patient’s
continued eligibility
Certification/ Recertification
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NHPCO Certification/ recertification Process Maps
available for purchase in NHPCO’s Marketplace
Co-morbidities
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Although not the primary hospice diagnosis, the
presence of disease such as the following…should be
considered in determining hospice eligibility
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Chronic obstructive pulmonary
disease
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Congestive heart failure
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Ischemic heart disease
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Diabetes mellitus
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Neurologic disease (CVA, ALS,
MS, Parkinson’s)
•
•
•
•
Renal failure
Liver Disease
Neoplasia
Acquired immune deficiency
syndrome
• Dementia
Local Coverage Determination Policies (LCDs)
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GUIDELINES, not regulations:
 Developed by each MAC (CGS, NGS, NHIC,
Palmetto)
 Outline guidelines for condition-specific
determination of eligibility
 Discuss documentation of secondary diagnoses and
co morbid conditions to support terminal prognosis
Local Coverage Determination Policies (LCDs)
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More emphasis on functional decline in the
updated LCDs
 Must have details to document the extent of
decline
 Need to consider the impact of disease on
patient’s quality of life
Be familiar with the LCDs that are used in
medical review for your region
Documentation Using LCDs
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Documentation needs to address:
 Impairments in function & structure
 Activity limitations
 Participation restrictions
 Secondary diagnoses
 Co-morbid conditions
Documentation Using LCDs
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Address the patient’s activity level, self care,
communication, and mobility
Give a historical perspective of what the patient’s
ability was in the previous time period and then
document current status
BUT REMEMBER…
 Decline  eligibility
 Decline  necessary or sufficient
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Documentation Using LCDs
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Use specifics to show the extent of the symptoms
and limitations
Use the term “as evidenced by” to qualify the
problems
Include symptoms such as wt loss, decubitus ulcers, &
edema
Co-morbid conditions such as CHF, COPD and
diabetes affect prognosis
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
 Reference
to specific LCDs as appropriate
to prognostic indicators or symptom
management sales as appropriate
The physician narrative
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Components of a comprehensive and adequate
physician narrative should include:

Reference to functional status
PPS - Validated in palliative care
 ECOG - Cancer
 Karnofsky - Cancer
 FAST - Dementia
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Being specific is the most important thing: don’t say that the
patient has lost weight – state that there has been a 15
pound weight loss in the past 2 months and 45 pounds in the
last 6
The physician narrative
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Components of a comprehensive and adequate
physician narrative should include:
Evidence of a decrease in anthropomorphic measurements
 Recent hospitalizations
 Information about other significant complications in addition
to the LCD specific criteria appropriate for that particular
diagnosis
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Statement should be concise, but adequate
Statement should contain prognostic indicators
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2011 Top 10 Survey Deficiencies
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#1
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§418.56(b) Standard: Plan of care
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L543
 All
hospice care and services furnished to patients and
their families must follow an individualized written plan of
care established by the hospice interdisciplinary group in
collaboration with the attending physician (if any), the
patient or representative, and the primary caregiver in
accordance with the patient’s needs if any of them so
desire
L543 deficiency examples
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Examples:
 The
POC listed hospice aide services 2x/wk. During a 6
wk period, the aide was provided 1 time.
 POC included SW every 2 weeks, the SW visits were
provided once a month.
 POC included SW Q2 weeks; the SW went once in a 7
week period.
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#2
§418.76(h) Standard: Supervision of
hospice aides
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L629
 (1)
A registered nurse must make an on-site visit to the
patient’s home:
 (i)
No less frequently than every 14 days to assess the quality
of care and services provided by the hospice aide and to
ensure that services ordered by the hospice interdisciplinary
group meet the patient’s needs. The hospice aide does not
have to be present during this visit.
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L629 deficiency example
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Intervals of 17 days, 18 days and 20 days were
noted.
Failure of the RN to provide aide supervision at least
every 14 days placed the patients at risk for having
their personal needs adequately met.
Supervision by LPNs
Remember! If the RN makes a supervisory visit on a Tuesday, the next
supervisory visit is due by the Tuesday, which occurs 14 days later
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#3
§418.56(c) Standard:
Content of the plan of care
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L545
 The
hospice must develop an individualized written plan
of care for each patient. The plan of care must reflect
patient and family goals and interventions based on the
problems identified in the initial, comprehensive, and
updated comprehensive assessments. The plan of care
must include all services necessary for the palliation and
management of the terminal illness and related conditions
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L545 deficiency example
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Elderly pt with lung cancer that lived alone. Initial visit a goal
was developed for comfortable breathing pattern without
distress.
2 months later the SN visited and taught oxygen use. 2 days
later during an RN visit, the pt was trying the oxygen to see if
it helps.
The following day the chaplain visited and described the pt as
upset. The chaplain documented that the landlady was upset
that the pt had oxygen in her apartment. The chaplain assisted
the pt to call the DME company to have the oxygen removed.
There was no indication that the chaplain contacted the
SN/case manager or the MD regarding the pt’s concerns and
wishes to discontinue the oxygen.
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#4
§418.54(c)(6) - Drug profile
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L530
A
review of all of the patient's prescription and over-thecounter drugs, herbal remedies and other alternative
treatments that could affect drug therapy. This includes, but
is not limited to, identification of the following:
i.
ii.
iii.
iv.
v.
Effectiveness of drug therapy
Drug side effects
Actual or potential drug interactions
Duplicate drug therapy
Drug therapy currently associated with laboratory
monitoring
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L530 deficiency examples
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The hospice failed to ensure a review of medications
on the initial comprehensive assessment for 8 of 8
patients. This was confirmed with clinical record
review and interviews with the administrator.
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#5
§418.56(e) Standard: Coordination
of services
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
The hospice must develop and maintain a system
of communication and integration, in
accordance with the hospice’s own policies and
procedures, to(1) Ensure that the interdisciplinary group maintains
responsibility for directing, coordinating, and
supervising the care and services provided.
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§418.56(e) Standard: Coordination
of services
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L555- Ensure that the care and services are provided
in accordance with the plan of care.
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L555 deficiency examples
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

A pt residing in an ALF did not receive 2 medications
(Lasix and Spirolactone) in accordance with the POC.
The patient was on automatic refills but because there
were temporary changes to the dosages the auto
refills were placed on hold.
The pt went without these meds for approximately
one month. As soon as the RN realized, she contacted
the MD and both meds were resumed.
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#6
§418.64(b) Standard: Nursing services
§418.64(b) Standard: Nursing services
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L591
(1) The hospice must provide nursing care and
services by or under the supervision of a registered
nurse. Nursing services must ensure that the nursing
needs of the patient are met as identified in the
patient’s initial assessment, comprehensive
assessment, and updated assessments.
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L591 deficiency examples
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No measurements of wounds.
A hospice aide was changing the dressings to a
patient’s neck and around the feeding tube on a
regular basis. The RN was aware of this practice
although the RN never instructed her to do this; she
acknowledged that she knew this was happening.
These dressing changes were outside the scope of the
hospice aide’s practice. No evidence in the clinical
record that the RN provided any wound care or
assessment.
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#7
§418.56(d) Standard:
Review of the plan of care
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L552
 The
hospice interdisciplinary group (in collaboration with
the individual’s attending physician, if any) must review,
revise and document the individualized plan as frequently
as the patient’s condition requires, but no less frequently
than every 15 calendar days
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L552 deficiency example
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
For 3 of 6 patient’s clinical records reviewed the plans
of care were reviewed on a monthly basis. There
policy was for an every 14 day review.
For 5 of 10 patients, the regulation was not followed.
The length of time between reviews ranged from 19
to 33 days. The agency policy was for every 2 weeks.
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#8
§418.64(d) - Counseling services
Bereavement counseling.
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L596
 (1)
- Bereavement counseling. The hospice must:
 (i)
Have an organized program for the provision of
bereavement services furnished under the supervision of a
qualified professional with experience or education in grief or
loss counseling
 (ii) Make bereavement services available to the family and
other individuals in the bereavement plan of care up to 1 year
following the death of the patient. Bereavement counseling also
extends to residents of a SNF/NF or ICF/MR when appropriate
and identified in the bereavement plan of care
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§418.64(d) - Counseling services
Bereavement counseling
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L596
 (1)
- Bereavement counseling. The hospice must:
 (iii)
Ensure that bereavement services reflect the needs of the
bereaved.
 (iv) Develop a bereavement plan of care that notes the kind of
bereavement services to be offered and the frequency of
service delivery.
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L596 deficiency examples
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
Bereavement files in the survey sample failed to
contain a bereavement reassessment or bereavement
plan of care for the deceased patient’s family
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#9
§418.76(c) Standard: Competency
evaluation
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L615


An individual may furnish hospice aide services on behalf of
a hospice only after that individual has successfully
completed a competency evaluation program as described
in this section.
§418.76(c)(1) - The competency evaluation must address
each of the subjects listed in paragraph (b)(3) of this
section. Subject areas specified under paragraphs (b)(3)(i),
(b)(3)(iii), (b)(3)(ix), (b)(3)(x) and (b)(3)(xi) of this section
must be evaluated by observing an aide’s performance of
the task with a patient. The remaining subject areas may be
evaluated through written examination, oral examination, or
after observation of a hospice aide with a patient.
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L615 deficiency examples
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

The hospices policy was to review the skills of the
aides 90 days after hire. 4 of the 4 files had no
evidence of a skills check at the 90 days per agency
policy.
There was no evidence of a skills checklist at the time
of hire, either in practice or in policy.
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#10
§418.54(b) Standard: Timeframe for
completion of the comprehensive assessment
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L523
 The
hospice interdisciplinary group, in consultation with the
individual’s attending physician (if any), must complete the
comprehensive assessment no later than 5 calendar days
after the election of hospice care in accordance with
§418.24.
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L523 deficiency example
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

No nursing or psychosocial assessment documented in
5 calendar days
Entire comprehensive assessment completed by 7 days
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Quality Reporting
CY2013 QUALITY REPORTING
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Measures for quality reporting:


NQF #0209 Pain Measure
Structural Measure
CY2013 QUALITY REPORTING
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1.
NQF #0209: Comfortable Dying (NHPCO)
Percentage of patients who were uncomfortable
because of pain at the initial assessment (after
admission to hospice services) whose pain was brought
to a comfortable level within 48 hours.
CY2013 QUALITY REPORTING
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Structural Measure:
Participation in a QAPI program that includes at
least 3 quality indicators related to patient care
CY2013 QUALITY REPORTING
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QAPI Structural Measure
Submission =
 Indication if hospice has a QAPI program that
includes at least three indicators related to patient
care; and
 Measures are used during reporting period
 Description of all quality indicators related to
patient care.
CY2013 QUALITY REPORTING
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QAPI Structural Measure
No results are submitted -- only the patient care
measure descriptions
Hospice Quality Reporting
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



The data collection period is January 1 – December
26 of each year
Reporting is mandatory
Data due April 1 of each year
2013 measures remain the same as 2012
Miss the deadlines?
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Mandatory reporting
 Measures required – no choice in what
measures should be reported
 Miss the 2013 reporting deadlines?



Deadlines HAVE NOT been extended
2% cut in hospital market basket increase
(hospice reimbursement rate “inflation
adjustment”) in FY2014
CMS RESOURCES
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CMS Hospice Quality Reporting web page
Information posted on CMS web site as it becomes
available
https://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/Hospice-QualityReporting/index.html
Download PowerPoint presentations and hospice quality
questions and answers:
http://www.cms.gov/Hospice-Quality-Reporting/
Help Desk: [email protected]
or by phone at 1.800.647.9670.
NHPCO RESOURCES
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Basic Information and Materials

www.nhpco.org/outcomemeasures

www.nhpco.org/qualityreporting
Questions – send email to:

[email protected]
89
THE FUTURE OF HOSPICE QUALITY REPORTING
Payment Year FY2015
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

NQF #0209: Percentage of patients who report being
uncomfortable because of pain on the initial assessment
(after admission to hospice services) who report pain
was brought to a comfortable level within 48 hours
Structural measure: Participation in a Quality
Assessment and Performance Improvement (QAPI)
program that includes at least three quality indicators
related to patient care. Hospices would report whether
or not they have a QAPI program with at least three
indicators related to patient care.
Data Collection Period
91



Calendar year – January 1, 2013 through
December 26, 2013
Hospices submit data in the fiscal year prior to the
payment determination.
For FY2015 and beyond: Data submission deadline
of April 1of each year.
Payment Year FY2015
92


No additional measures
Creation of a hospice patient-level data item set
 Target

date for implementation: CY2014
Data items included in standardized data set to
support possible measures
Patient level data collection
93



Mandatory data collection process being designed
to collect data on individual hospice patients –
demographics, diagnoses, symptoms
Used to collect data for future quality reporting
Expect to see a form and process in 2014 or 2015
STANDARDIZED DATA ITEM SET
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CMS developing standardized assessment instrument





Many items standardized and used by other providers
Some items developed specifically for hospice
Developed to collect information for hospiceappropriate quality measures
Pilot testing with 9 hospices summer/fall 2012
Propose to implement hospice patient-level data item
set as early as CY 2014
Payment Determinations beyond FY2015
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
Possible measures – implemented in future
rulemaking
 1617
Opioid with bowel regimen
 1634 Pain screening
 1637 Pain assessment
 1638 Dyspnea treatment
 1639 Dyspnea screening
 0208
Family Evaluation of Hospice Care
Experience of Care Survey
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

Similar to FEHC
CAHPS survey being developed now
VALUE BASED PURCHASING
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
Value based purchasing – pilot testing


Utilize already implemented measures
Implement pilot by January 1, 2016
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Part D and Hospice
Part D and Hospice
99



OIG report issued in 2012
Some Medicare hospice beneficiaries receiving
hospice care also had drugs paid for under Part D
Scope of the problem:
198,543 hospice beneficiaries
 677,022 prescription drugs through Part D
 Drugs should have been covered by the hospice?
 Part D paid pharmacies $33,638,137
 Beneficiaries paid $3,835,557 in copayments


Expect additional scrutiny for Part D payments
Recent Analysis
100


Analgesics only
2010 information
 773,168
Medicare hospice beneficiaries enrolled in
Part D
 112,555 (14.6%) received 334,387 analgesic
prescriptions through Part D during hospice enrollment
 Gross costs -- $13,000,430
 Examples of drugs: Fentanyl, oxycodone, morphine,
hydrocodone, hydromorphone….
Recent Analysis
101

Location of patients?
 63%
in nursing facilities and assisted living
 35% at home

Which hospices?
 96.7%

of hospices billed some analgesics to Part D
Which pharmacies?
 40.9%
of pharmacies
CMS Draft 2014 Call Letter
102



Questions about eliminating Part D payments for Medicare
hospice patients
Comments submitted March 1 2013
Proposing January 2014:



Part D sponsor who receives report that a beneficiary has elected
the Medicare Hospice benefit
Sponsor place beneficiary-level prior authorization requirement
for four categories of prescription drugs
Four categories:




Analgesics
antinauseants (antiemetics)
Laxatives
antianxiety
103
Multiple diagnoses on claim form
Multiple diagnoses on claim form
104


Requirement is not new
Clarification in FY 2013 Final Hospice Wage Index
Rule
 Analyses
by CMS hospice contractor, showed that
77.2% of hospice claims from 2010 only reported a
principal diagnosis
 CMS
believes that hospice claims which only report a
principal diagnosis are not providing an accurate
description of the patients’ conditions
Multiple diagnoses on claim form
105

Providers should code and report coexisting or
additional diagnoses to more fully describe the
Medicare patients they are treating

CMS’ Hospice Claims Processing manual requires that
hospice claims include other diagnoses “as required by ICD9-CM Coding Guidelines” (IOM 100-04, chapter 11, section
30.1, available at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c11.pdf)
Multiple diagnoses on claim form
106

CMS clarifies that all of a patient’s coexisting or
additional diagnoses s should be reported on the
hospice claim
 paper
UB-04 claim allows for up to 17 additional
diagnoses
 electronic claim allows for 24 additional diagnoses

Hospices should not report diagnoses which are
unrelated to the terminal illness on their claims
Mixed messages from CMS
107



CMS is asking for all coexisting diagnoses and
comorbidities
Often significant and used to make the case in the
narrative for 6 month life expectancy
Example:
Patient with heart failure
 Significant COPD and Parkinson’s disease
 COPD and Parkinson’s contributing to decline
 “Unrelated” to the heart failure
 Previously instructed not to include these very significant but
unrelated diagnoses on claim form

The issues
108

Diagnoses definition inconsistency by CMS
 Related
 Co-morbid
 Secondary


Many EMR software solutions do not allow more that
one diagnosis (5010 allows 25 spaces)
Payment for non-related dx; concern of providers
Corollary issues
109

If diagnosis on claim form….
Hospice responsible for paying for drugs, DME, supplies
related to diagnosis
 CMS will expect hospice to pay for all or nearly all drugs,
DME, supplies for broad diagnoses





Debility
Adult Failure to Thrive
Others
Determining relatedness…..
Joint task force – NHPCO & NAHC
110

Task force goals
 Refine
diagnoses definitions and seek clarification from
CMS
 Develop a resource to assist hospice providers to
determine relatedness
 Diagnoses
 Medications
 Other
supplies and services
111
Illegal aliens
Provider responsibility
112



Medicare does not pay for medical items/services
furnished to an alien beneficiary who was not
lawfully present in the United States on the date of
service that the items/services were furnished
Common Working File will indicate alien status for
unlawfully present in the US
MAC will retroactively adjust previously paid claims
113
2013 PEPPER report
PEPPER Report
114




The Program for Evaluating Payment Patterns
Electronic Report (PEPPER) second report
Available April 2013
FedEx to the hospice CEO
Hospice-specific data statistics
PEPPER Details
115





CMS sets PEPPER focus areas
Services at risk for improper payments
Three years of claims data
Hospices can use the data to support internal auditing
and monitoring activities
PEPPER compares a hospice’s Medicare billing practices
with other hospices in the:
State
 Medicare Administrative Contractor (MAC) jurisdiction
 US

PEPPER Details
116


Time frame for claims: October 1, 2009 –
September 30, 2012
Additional claims for period October 1, 2007 –
September 30, 2009 included for episodes of
service beginning prior to the reporting period
PEPPER Details
117




Each hospice receives only its PEPPER
Not available to the public
Contractor provides Access database with PEPPER
data to MACs, Recovery Audit Contractors
Pay attention to any findings at or above the
national 80th percentile
Focus of PEPPER Report
118


Beneficiaries whose episode of service ends in the
reporting year, either by live discharge or death.
Two focus areas:
 “Live
Discharges” includes all episodes where the
beneficiary was discharged alive with a length of stay
less than 25 days
 “Long Length of Stay” counts beneficiary episodes of
service that had a long length of stay -- greater than
180 days
PEPPER Resources
119

www.pepperresources.org
120
HIPAA Omnibus Rule
The final omnibus rule
121

The final omnibus rule was published in the January
17, 2013 Federal Register



http://www.gpo.gov/fdsys/pkg/FR-2013-0125/pdf/2013-01073.pdf
Compliance with most of the new requirements
introduced in the Final Rule is required by September
23, 2013
An extended compliance period is provided for the
modification of certain existing business associate
agreements
When is compliance required?
122


Effective date: This final rule is March 26, 2013
Compliance date: Covered entities and business
associates must comply with the applicable
requirements of this final rule by September 23,
2013
New rule
123


Changes greatly enhance a patient's privacy rights
and protections
Strengthens the ability of Office of Civil Rights to
vigorously enforce the HIPAA privacy and security
protections
New Breach Standard
124


Substantial change to the definition of a “breach” of
protected health information (PHI)
New standard defines any impermissible acquisition,
access, use or disclosure of PHI under the Privacy Rule
is a breach unless a covered entity or business
associate can demonstrate that there is a low
probability that the PHI has been compromised

Entities determine whether there is a low probability that PHI
has been compromised by performing a risk assessment
New Breach Standard
125


This modification to the definition of breach will
make it more difficult for covered entities and
business associates to justify a decision not to provide
notification following a suspected breach incident
Following a breach, covered entities are still required
to notify affected individuals, the Secretary of HHS,
and the media (if a breach affects more than 500
residents of a State or jurisdiction)

The current timing, content and methods for notification also
remain unchanged
New Breach Standard
126

HHS intends to issue guidance to aid covered entities
and business associates in performing risk
assessments and to assist with the individual
notification requirements at a future date
Expanded Individual Rights
127

Individuals’ rights expanded with respect to their PHI
in two important ways
1.
2.

It provides them with the right to receive certain PHI
electronically
It allows them to restrict certain disclosures of PHI to
their health plans
Hospice providers will have to revise their current
policies and procedures and evaluate current system
capabilities to ensure compliance with these new
requirements
Expanded Individual Rights
128



The Final Rule also provides individuals with the right
to request that covered entities and business
associates provide a copy of their PHI directly to a
designated individual
This right applies to both paper and electronic
information
Any such request must be in writing, signed by the
individual, and must clearly identify the designated
recipient and where the information should be sent
Expanded Individual Rights
129


Restriction of certain disclosures of PHI to their health
plans
Hospice providers will likely need to develop a
method to flag or include a notation in the record of
any individual who has exercised this right to restrict
disclosures regarding services paid for out of pocket,
in order to ensure that specific records are not sent or
made accessible to health plans
Modifications to Notices of Privacy
Practices Required
130


Privacy notices must include a statement regarding
the right of affected individuals to be notified
following a data breach and must describe certain
uses and disclosures of PHI that require patient
authorization related to psychotherapy notes,
marketing, and the sale of PHI
The Notice must also inform patients of their right to
restrict certain disclosures of PHI to health plans
where the individual pays out of pocket in full
Direct Liability for Business Associates and
Amendments to Business Associate Agreements
131

Business associates and business associate
subcontractors will now be directly subject to
applicable HIPAA rules
 including
the HIPAA Security Rule and certain provisions
of the Privacy Rule

HHS modified the definition of business associates to
specifically include several new entities, including
subcontractors that create, receive or transmit PHI on
behalf of business associates and entities that
provide data transmission of PHI
Direct Liability for Business Associates and
Amendments to Business Associate Agreements
132

Data storage vendors that maintain PHI (both
hardcopy and electronic), are business associates even
if the vendor never actually views or accesses the PHI
Business Associate Agreements
133


Business associate agreements will need to be
modified to meet additional requirements
The Final Rule provides an extended transition period
up to September 22, 2014 for amending existing
business associate agreements only for an existing
business associate agreement meeting the following
conditions:
 was
in place prior to January 25, 2013 and complies with
current HIPAA business associate agreement requirements;
and
 is not modified or renewed during the period from March
26, 2013 to September 23, 2013
Business Associate Agreements
134


Business associate agreements not eligible for the
extended transition period must be compliant with
the Final Rule as of the September 23, 2013
compliance date
HHS recently issued guidance on the revised
business associate agreement requirements and
provided sample terms. This guidance is available
at:

http://www.hhs.gov/ocr/privacy/hipaa/understanding/cove
redentities/contractprov.html
New Fundraising Requirements
135



Expansion of the type of information covered entities
may use to target fundraising appeals to include the
department of service, the treating physician and
outcome information
Permits the use only of demographic information and
dates of health care provided to the patient
Fundraising communications must provide recipients
with a clear opportunity to opt-out and the method
provided for the opt-out may not cause undue burden
or more than nominal costs
Decedent information
136


A covered entity only has an obligation to comply with
the requirements of the Privacy Rule with respect to
the PHI of a deceased individual for 50 years
following the individual’s death
Rule permits covered entities to disclose PHI to a
family member or other individual involved in a
decedent’s care or payment for such care, unless such
a disclosure is inconsistent with a prior expressed
preference of the decedent
New Enforcement Authority
137




Enforcement changes effective March 26, 2013
Civil and criminal penalties can now be applied
directly to business associates
HHS must investigate any complaint and conduct
compliance reviews in all cases where a preliminary
review of the facts indicates a possible violation due
to willful neglect
HHS must impose a civil money penalty for violations
due to willful neglect
New Enforcement Authority
138


HHS is not required to attempt to resolve cases of
noncompliance due to willful neglect by informal
means
The tiered penalty structure based on different levels
of culpability has been finalized. Penalties now range
from $100 to $50,000 per violation depending on
the level of knowledge/willfulness with a $1.5 million
cap per calendar year for multiple violations of
identical provisions
New Enforcement Authority
139


Covered entities and business associates can be
subject to liability for a violation by their business
associate agents and subcontractor business associate
agents respectively
HHS may disclose PHI obtained in connection with a
compliance review or investigation if permitted under
the Privacy Act, thereby giving it the ability to share
information with other law enforcement agencies (e.g.,
state attorneys general or the Federal Trade
Commission)
Other Important Changes
140

Expansion of Prohibited Marketing Activities


HIPAA prohibits the use or disclosure of PHI for marketing to
individuals without obtaining an authorization, with certain
important exceptions
Prohibition on the Sale of PHI
Prohibits the receipt of direct or indirect remuneration
(including in-kind benefits) in exchange for PHI
 This new restriction includes several exceptions, including
disclosures to business associates, as required by law, and for
treatment and payment purposes

Other Important Changes
141

New Research Authorizations Permitted

allows researchers to obtain authorizations to use PHI for
future research, provided that the future research is
adequately described
142
FY 2013 OIG WORK PLAN
AND RISK AREAS FOR
HOSPICE
OIG Compliance Guidance
143




Published in 1999
Still valid today
28 areas of risk
Find complete list at:
www.nhpco.org/regulatory/fraud and abuse
143
OIG Identified Risk Areas
144
1. Uninformed consent to elect the Medicare Hospice Benefit
2. Admitting patients to hospice care who are not terminally ill.
 Certification of Terminal Illness 42 CFR § 418.22
 Face-to-Face Encounter – 42 C.F.R. § 418.22 (a)(4)
 “Clinical information and other documentation that support
the medical prognosis must accompany the certification and
must be filed in the medical record with the certification.”
418.22(b)(2)
 Admission to Hospice 42 C.F.R. § 418.25
3.
4.
5.
Arrangement with another health care provider who a hospice
knows is submitting claims for services already covered by the
Medicare Hospice Benefit
Under-utilization
Falsified medical records or plans of care.
OIG Identified Risk Areas
145
6.
Untimely and/or forged physician certifications on
plans of care.
7. Inadequate or incomplete services rendered by the
Interdisciplinary Group (IDG).
8. Insufficient oversights of patients receiving more than
six consecutive months of hospice care.
9. Hospice incentives to actual or potential referral
sources (e.g., physicians, nursing homes, hospitals,
patients, etc.) that may violate the anti-kickback statute
or other similar Federal or State statute or regulation,
including improper arrangements with nursing homes.
10. Overlap in the services that a nursing home provides,
which results in insufficient care provided by a hospice
to nursing home resident
OIG Identified Risk Areas
146
11. Improper relinquishment of core services and
professional management responsibilities to nursing
homes, volunteers, and privately-paid professionals.
12. Providing hospice services in a nursing home before a
written agreement has been finalized.
13. Billing for a higher level of services than was necessary.
14. Knowingly billing for inadequate or substandard care.
15. Pressure on a patient to revoke the Medicare Hospice
Benefit when the patient is still eligible for and desire
care but the care has become too expensive for the
hospice to deliver.
OIG Identified Risk Areas
147
16. Billing for hospice care provided by unqualified or
unlicensed clinical personnel.
17. False dating of amendments to medical records.
18. High-pressure marketing of hospice care to ineligible
beneficiaries.
19. Improper patient solicitation activities, such as “patient
charting.”
20. Inadequate management and oversight of
subcontracted services, which results in improper billing.
21. Sales commissions based upon length of stay in hospice.
OIG Identified Risk Areas
148
22. Deficient coordination of volunteers.
23. Improper indication of the location where hospice services
were delivered.
24. Failure to comply with applicable requirements for verbal
orders for hospice services.
25. Non-response to late hospice referrals by physicians.
26. Knowing misuse of provider certification numbers, which
results in improper billing.
27. Failure to adhere to hospice licensing requirements and
Medicare conditions of participation.
28. Knowing failure to return overpayments made by Federal
health care programs.
149
149
FY 2013 OIG Work Plan
FY2013 OIG Work Plan
150

Acute-Care Hospital Inpatient Transfers to Inpatient
Hospice Care


Hospice Marketing Practices and Financial
Relationships with Nursing Facilities


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

Use of GIP from 2005 to 2010. Assess appropriateness of
GIP claims and beneficiary drug claims billed under Part D.
150
FY2013 OIG Work Plan
151

Medicaid: Hospice Services: Compliance With
Reimbursement Requirements
 We
will determine whether Medicaid payments for
hospice services complied with Federal reimbursement
requirements.
151
152
HOSPICE MEDICARE/MEDICAID
FRAUD AND ABUSE
Risk areas for hospice
fraud and abuse
153

Eligibility
 Does
this patient meet the eligibility requirements for
admission to the hospice program?
 Does the documentation support eligibility?

Site of care
 Do
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?
153
Risk areas for
hospice fraud and abuse
154

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?

Claims submission
 Are
the dates of service, Q-codes for location of care,
and levels of care accurate?
154
Issues Being Audited
“Low Hanging Fruit”
155
•
•
•
•
•
•
•
Proper election
Timely certifications (verbal,
written, signed and dated
before billing)
Documentation of verbal
certifications
Brief physician narratives
Face-to-Face (completed
and timely)
Lack of attending physician
for initial certification
Lack of signatures/stamped
signatures





Has signature but no date
Use of continuous care in a
skilled nursing facility
Duplicate billing (two
providers for same date of
service i.e. hospice and
hospital)
Physician Billing
Medicare Part D billing
More Complex Issues Subject to Audits
156
1.
Lack of justification in the record for hospice eligibility
2.
Non-Cancer Length of Stay (NCLOS)
3.
Length of stay at General Inpatient (GIP) level of care
4.
Hospice services provided in the nursing home
5.
Lack of justification in the record for level of care provided
Types of Contractors
157
Contractors reviewing hospice claims:

(not all-inclusive)
Medicare






Medicare Administrative Contractors (MAC)
Recovery Audit Contractors (RAC)
Zone Program Integrity Contractors (ZPIC)
Office of Inspector General (OIG)
Department of Justice (DOJ)
Medicaid



State Medicaid agency audits
Medicaid Integrity Contractors (MIC)
Medicaid Recovery Audit Contractors (Medicaid RAC)
157
Medicare RACs
158

Three hospice-related issues
 DME
when hospice is involved
 Physician services when hospice is involved
 Outpatient hospital services when hospice is involved

First hospice-specific RAC audit
 Connolly
– automated pull of claims to determine
improper or outdated CBSA codes
ZPIC Contractors
159
ZPIC
Zone
States
Safeguard Services
(SGS)
1
California & Nevada
AdvanceMed
2
Washington, Oregon, Idaho, Utah, Arizona,
Wyoming, Montana, North Dakota, South Dakota,
Nebraska, Kansas, Iowa, Missouri, Alaska
Cahaba Safeguard
Services
3
Minnesota, Wisconsin, Illinois, Indiana, Michigan,
Ohio, Kentucky
Health Integrity
4
Colorado, New Mexico, Texas and Oklahoma
AdvanceMed
5
Arkansas, Louisiana, Mississippi, Tennessee,
Alabama, Georgia, South Carolina, Virginia, West
Virginia
Under Protest
6
Pennsylvania, New York, Delaware, Maryland,
D.C., New Jersey, Massachusetts, New Hampshire,
Vermont, Maine, Rhode Island, Connecticut
Safeguard Services
(SGS)
7
Florida
159
Goal of ZPICs
160




The primary goal of ZPICs is to investigate instances
of suspected fraud, waste, and abuse.
Conducting investigations in accordance with the
priorities established by Center for Program
Integrity’s Fraud Prevention System;
Performing medical review, as appropriate;
Referring to law enforcement as appropriate
160
Resources for Audits
161

Front office protocol
Mail room protocol
Pre-submission billing audit

Available soon at www.nhpco.org/regulatory


Contacts for Reporting Fraud
162


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).
162
163
Other Federal and State Laws
Federal and State Anti-Kickback Law
164


Prohibits, among other things, remuneration in
return for ordering, or for arranging for or
recommending the purchase or order of, any item
for which payment may be made in whole or in
part under a federal healthcare financing
program. 42 U.S.C. 1320a-7B(b).
Comply with federal safe harbor for 25 different
business relationships. For example, safe harbors
for space rental, personal service and
management contracts, equipment rental, referral
services, discounts, employees, group purchasing
organizations, investment interests, warranties,
waiver of beneficiary co-insurance and
deductibles, electronic and health records items
and services, etc. 42 C.F.R. § 1001.952
Federal and State Anti-Kickback Law
165

Referral Issues:



Providing staff, rental payments, meals and
entertainment, training, or back-up staff to referral
sources.
Providing payments to entities or individuals to refer
patients.
Providing services for free or reduced rate to the
patient, or potential patient/family.

Providers agreeing to provide referrals to each other.

Aides referring patients in exchange for hiring/bonus.

Aides changing agencies and bringing patients with
them from one agency to another.
Problematic Marketing Practices
Under Anti-Kickback Law
166
●
“Special Advisory Bulletin Regarding Provision
of Gifts and Other Inducements to Medicare
Beneficiaries,” 8/30/02 available at:
http://oig.hhs.gov/fraud/docs/alertsandbulletins/sa
bgiftsandinducements.pdf
●
Civil Money Penalties for inducements
•
•
•
“Remuneration”
$10 per item / $50 per year
Five exceptions
Five Statutory Exceptions
167





Waivers of cost-sharing amounts based on financial
need
Properly disclosed copayment differentials in health
plans
Incentives to promote the delivery of certain
preventive care services
Any practice permitted under the federal antikickback statute pursuant to 42 CFR 1001.952
Waivers of hospital outpatient copayments in excess
of the minimum copayment amounts.
Problematic Marketing Practices
Under Anti-Kickback Law
168
●
Free items or less than fair market value or
services contingent on purchases, or on access to
referral base
●
Payments disguised as grants
●
Travel, entertainment, gifts
●
Free consultants
●
Free CE/CEUs
●
Free Transportation
●
Courtesy visits to non-hospice patients
●
Waiver of cost sharing
Anti-Inducement Laws
169
●
ACA § 6402 excludes “certain charitable and other
innocuous programs.”
a. Remuneration which promotes access to care and poses
a low risk of harm to patients and Federal health care
programs;
b. The offer or transfer of items or services for free or
less than FMV if:
i. Coupons, rebates, or other rewards from retailer;
ii. Items offered on equal terms to
general public regardless of health
insurance status; and
iii. Offer or transfer is not tied to provision of
care reimbursed by Medicare or Medicaid.
Anti-Inducement Laws
170
c. Offer or transfer of items or services for
free or less than FMV by a person to an
individual in financial need if not part of
an ad or solicitation; not tied to care paid
for by Medicare or Medicaid; and there is
a reasonable connection between the item
or service and the medical care being
provided.
d. Effective March 23, 2010
e. Effective January 1, 2011, waiver of
certain co-pays under Part D for first
prescription under certain circumstances.
False Claims Act
171
•
•
•
•
•
•
•
Fraud Enforcement and Recovery Act of 2009 (FERA) – effective
May 20, 2009 – amends the FCA.
False or fraudulent claim for government payment exists
regardless of whether the claim was presented to the government
for payment.
Actual knowledge, deliberate ignorance, or reckless disregard
used to be intent requirement. Amended to eliminate the intent
requirement: “require no proof of specific intent to defraud.”
Sufficient that the false record or statement may be “material to a
false or fraudulent claim.”
Penalty from $5,500 to $11,000 per claim, plus treble damages.
Other penalties include criminal prosecution, exclusions, costs and
attorneys fees.
Qui tam provisions – whistleblower
Return of Overpayments
172
 ACA § 6402 defines overpayment as “any
funds that a person receives or retains
under Medicare or Medicaid to which the
person after applicable reconciliation is not
entitled . . .”
 Person includes provider of services, Medicaid managed
care organization, Medicare Advantage Plan and
Prescription Drug Plan.
 Report and return the overpayment to Medicare or
Medicaid within 60 days after O/P is identified or date
any corresponding cost report is due.
Return of Overpayments
173
 Failure to return money a provider is not
entitled to is considered a violation of the
FCA and subjects the provider to a penalty
of $5,500-$11,000 per claim
 Knowingly concealing or failing to disclose
occurrence of event affecting right to
payment –
42 U.S.C.1320a-7b(a)(3)
 Criminal Sanction
174
COMPLIANCE
What the Government Expects…
175
A provider has a duty to have knowledge of the statutes,
regulations and guidelines regarding coverage for
Medicare services including but not limited to, the following:


Medicare reimburses only reasonable and necessary
medical services furnished to beneficiaries. 42 U.S.C. §
1395y(a)(1)(A)
Providers must assure that they provide economical
medical services and then, only when, and to the
extent medically necessary. 42 U.S.C. § 1320c-5(a)(1)
What the Government Expects…
176
Medicare regulations exclude payment for services
that are not reasonable and necessary…. 42 U.S.C.
§ 411.15(k)
It is a Condition of Participation that hospices must
maintain a clinical record for each hospice patient
that contains “correct clinical information” All entries
in the clinical record must be “legible, clear,
complete, and appropriately authenticated and
dated…” 42 C.F.R § 418.104
What the Government Expects…
177
A sophisticated hospice provider….is expected to fully know and
appreciate the Medicare statute, the definition of “terminally ill”
and the local coverage determinations that set out medical
criteria for determining whether individuals with certain
diagnoses have a prognosis of six months or less to live.
The purpose of the Medicare requirements is to ensure that the
limited Medicare funds are properly spent on services actually
needed by Medicare beneficiaries. [Hospice] has a duty to deal
honestly with the Government. (Recent hospice case)
Compliance plans
178

Vigilance is required about compliance activities

Compliance with:
Medicare Hospice Conditions of Participation
 Other hospice regulations
 Claims submission requirements
 Eligibility requirements
 Requirements for continued eligibility


Compliance plan should include:
Specific timeframes for internal audits of agency practices
 Protocol for reviewing processes that may be out of
compliance with current laws and regulations.

178
179
Seven Elements of a Compliance
Program for Hospices
Compliance Programs for Hospices
180
Seven Elements:
Written Policies, procedures and standards of conduct
2. Compliance officer and compliance committee
3. Effective training and education
4. Develop effective lines of communication
5. Enforce standards through well publicized disciplinary
guidelines
6. Conduct internal auditing and monitoring
7. Respond promptly to detected offenses and develop
corrective actions
1.
#1: Written Policies, Procedures and
Standards of Conduct
181
Code of Business Ethics and Conduct:
Commitment to full compliance with all Federal and State
health care program requirements.
 Expectation that all associates will comply with these
requirements.
 Report suspected violations of any Federal/State law or
regulation or company’s policies to the Compliance Officer, or
other appropriate individual.
 Report concerns through the Company Compliance Officer
 Commitment to non-retaliation against employees who
disclose compliance concerns.
 Maintain, as appropriate, the confidentiality and anonymity
of these employees, with respect to such disclosures

#1: Written Policies, Procedures and
Standards of Conduct
182

Written Policies and Procedures:
Comprehensive and comprehensible
 Distributed /available to all employees
 Frequently updated


Risk Areas:
Should be addressed in written policies
 OIG identified 28 risk areas –
 (OEI-04-93-00270 – Medicare Hospice
Beneficiaries: Services and Eligibility)
 Still relevant today especially : Eligibility, Consent, AntiKickback

#1: Written Policies, Procedures and
Standards of Conduct
183

Records and Documentation:
 Medical
Record and Billing Process/Records
 Compliance Program Documentation:
 Training,
Hotline calls, corrective action plans, selfdisclosures, audit and monitoring results, program
modifications

Compliance as an Element of a Performance Plan
#2: Compliance Officer and Compliance
Committee
184
Compliance Officer:
Integrity, Independence, Authority
•
•
•
•
•
•
•
Oversee/monitor the compliance program
Reports to Governing Body, Board of Directors, CEO and
Compliance Committee
Revises Program r/t regulatory, and/or statutory changes
Develops and participates in training
Independent Contractors
OIG/GSA checks
Investigations
#2: Compliance Officer and Compliance
Committee
185
Compliance Committee:
•
•
•
•
•
•
Senior management, drawn form all departments
Assist and support the compliance officer
Analyze and review legal requirements
Review/revise existing policy
Determine strategy
Monitor internal and external reviews
#3: Effective Training and Education
186
•
All Staff: corporate officers, senior
management, volunteers, nurses, physicians, other
clinical staff, administrative, marketing and
financial services.
•
•
•
•
Annual, mandatory, post-tests and
employee attestations
Business Ethics and Compliance
HIPAA
Features of the Medicare Hospice Benefit
#3: Effective Training and Education
187
•
•
•
•
•
Election, eligibility and consents
Regulations, statutes and COPs related to
Medicare Program Integrity
Patient rights
Duty to comply and report misconduct
Marketing
#4: Develop Effective Lines of
Communication
188

Access to the Compliance Officer
 Unfettered
access to the compliance officer
 Non-retaliation
 Confidential and anonymous (some caveats
here)
#4: Develop Effective Lines of
Communication
189

Hotline and Other forms of Communication
 Confidential




Confidential and anonymous
Readily available
Distributed to all
Appropriate follow-up to calls: log, investigations,
reports
 E-mail,
used
Hotline
suggestion box, newsletters etc. can also be
#5: Enforce Standards Through Well
Publicized Disciplinary Guidelines
190

Effective Disciplinary Policies and Actions





Well disseminated
Effective
Fair and equitable
Enforced
New Employee Policies

Background checks
OIG/GSA Exclusion Lists

State Medicaid exclusion lists

#6: Auditing and Monitoring
191









Pre-bill Audits
Internal Review
Admission Audits
Certification Audits
Recertification Audits
Investigation of Hotline calls and other complaints
Patient/family complaints
Collate data – review trends – provide feedback
Act on findings – education, plan of correction,
discipline
Provider Self Audits
192





Publication 100-08
1.3.9 – Provider Self Audits (Rev. 425, Issued: 06-15-12, Effective: 07-16-12, Implementation; 07-16-12)
Providers may conduct self-audits to identify coverage and coding errors. The
Office of Inspector General (OIG) Compliance Program Guidelines can be found at
http://oig.hhs.gov/compliance/compliance-guidelines/index.asp and the statistical
guidelines in http://oig.hhs.gov/authorities/docs/selfdisclosure.pdf (if statistical
sampling is utilized during the audit). ACs and MACs shall follow chapter 4, section
4.16, handling any voluntary refunds that may result from these provider self-audits.
Most errors do not represent fraud. Most errors are not acts that were committed
knowingly, willfully, and intentionally.
However, in situations where a provider has repeatedly submitted claims in error,
the ACs and MACs shall follow the procedures listed in chapter 3, section 3.2.1. For
example, some errors will be the result of provider misunderstanding or failure to pay
adequate attention to Medicare policy. Other errors will represent calculated plans to
knowingly acquire unwarranted payment. Per chapter 4, section 4.2.1, ACs and MACs
shall take action commensurate with errors made. ACs and MACs shall evaluate the
circumstances surrounding the errors and proceed with the appropriate plan of
correction.
#7: Respond to Detected Offenses and
Develop Corrective Action initiatives
193

Failure to respond to/correct detected potential
violations can seriously endanger the mission,
reputation and legal status of the hospice.
“…..disregarded concerns expressed by its staff and
auditor that the organization was admitting and retaining
patients who were not eligible for Medicare hospice
benefits.”
 “In spite of these warnings and red flags…it has provided
no information or documentation to show that it made
changes to its business practices or took corrective actions. It
did not contact Medicare officials to request guidance or to
report errors or overpayments of Medicare dollars”

#7: Respond to Detected Offenses and
Develop Corrective Action initiatives
194




Report misconduct within a reasonable period
 Demonstrates good faith
 Failure to do so might be construed as a deliberate attempt
to conceal findings from the Govt.
 Provide evidence of the violation and estimate of the
overpayment that resulted from it.
 Return the overpayment (See return of overpayments)
Demand plan of correction
Implement corrections to practices and required disciplinary
action
Evaluate effectiveness of corrective actions
195
Deliberate ignorance
is not a defense!
Q&A
196
NHPCO members enjoy unlimited access to Regulatory Assistance
Feel free to email questions to [email protected]
Regulatory and Compliance Team
at NHPCO
197
Jennifer Kennedy, MA, BSN, RN
Regulatory and Compliance Director
Judi Lund Person, MPH
Vice President, Compliance and Regulatory
Leadership
Email us at: [email protected]