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Dealing with Home Care Investigations-OIG
Chris AndersonVice President, Audit Services and
Quality Assurance & Chief Compliance Officer
Old History and Today’s Context
è 51% of those hospitals surveyed did not have a compliance program in operation
è Of those respondents that did not have a compliance program in operation, only 50% are considering instituting such a program
è 72% of respondents have a code of conduct or a compliance policy
è Of those 72%, only 66% reported that all of the organization’s employees were made aware of the code of conduct
è Of the 49% of respondents that do have a compliance program in place, only 27% of respondents reported that a hotline is part of their compliance program
Source: Corporate Compliance Officer, February 1998 (Survey of 202 hospital CEOs by Health Care Compliance Association)
Investigations & Compliance
• Olsten Corporation• Investigation covered 5 year period• Transaction with a large hospital system• FMV of transaction• The “kitchen sink”
Badges & Bullets
• Multiple “raids”• Sophisticated bugging and techniques• Qui Tam- The Million Dollar Crap Shoot• Subjective-Not Qualitative• “Let the contest begin.”
Settlement
• Who’s got the time?• The Acquisition of Olsten• The result:
• $62 Million• Criminal Pleas• Civil Penalties• 5 Year Corporate Integrity Agreement
The Aftermath
• Management turnover• Launch of aggressive compliance efforts• Re-defining the culture• Living under the shadow• Build the future
CIA Preparation
• Look at the case elements• Self Disclosure• Qui Tam• “Industry” Audit
• Hot Investigative Topics• Billing
• Coding/ Procedures
• Sales Practices• Pricing Schemes• Utilization
• Trends• Reliance by OIG on
Integrity Agreements• CIA’s moving towards
“punitive assurances”• Length of time
increases• Adds perhaps
significant cost to “true settlement figure”
Understand Your Case
• Most, if not all, companies significantly utilize outside resources for internal or “shadow” audits.
• Lag time between initial discovery/ investigation and settlement is typically lengthy.
• Compliance Officer should take case points and ensure adequate internal systems are in place and proven prior to negotiation of a CIA.
Research Existing CIA’s
• Understand what similar organizations have faced in final CIA.
• Take advantage of professional networking to help determine negative impacts.
• One constant: All CIA’s take a toll on financial and human resources regardless of existing compliance efforts.
Prepare Senior Leadership
• Understand Senior Management’s negotiation temperament.• Quick Settlement• Protracted Discussions
• Begin to define initial costs and work to keep or reduce cost level during negotiation.
• Re-evaluate compliance program to ensure internal mechanisms are sufficient.
Negotiation- Part I
• Involve Compliance Officer with direct OIG communications from the start.
• Compliance Officer should constantly represent existing compliance program• Focus on proactive processes relating to issue that gave rise to
investigation.• Show how processes have been effective in real terms.• Work to move the focus from standard requirements to existing
effective internal processes. • Minimize reliance on IRO audit- Use internal resources as much
as possible.
Negotiation- Part II
• After drafts have been exchanged, work with senior management to better determine what is palatable and what must continue to be negotiated.• Regardless of negotiation position, the effectiveness of existing
compliance efforts will generally be recognized.• Use counsel to better gauge soft and hard points.• Clarify or eliminate broad language or cumbersome verbiage.• Keep focus on issues that gave rise to investigation.
Negotiation- Part III
• Take full advantage of whatever compliance resource available to demonstrate the need to mold the CIA to fit your compliance program.• Training, auditing systems, active and closed cases, etc.• Move IRO review to mirror existing internal review process.• Make sure timeframes for reports are realistic for your
organization. • Implementation Report• Annual Report• Audit Period
Final Discussions
• Make an opportunity to meet with the OIG’s CIA Monitor that will be assigned to your CIA.
• Quickly determine and factor costs of implementation and on-going monitoring.
• Annotated CIA invaluable to compliance officer’s implementation of the Agreement.
• Prior to CIA finalization, review drafts to see where you went.
• Work with counsel and OIG to clearly address any unclear items.
• The negotiation team is not the same as the monitoring group-Leave no stone unturned.
• You have to run the CIA…
Supplemental Information
Olsten Health Services CIA Overview
July 1999
Investigative Issues
• Issues Raised in the Government Investigation• Olsten Health Management
• Selling home care agencies at below FMV prices in exchange for above FMV management agreement
• Cost Report Issue• Filing for costs not reimbursable by the Medicare program
Corporate Integrity Agreement
• Term: • 5 years
• Entities:• All company
businesses that provide and bill for services under a federal health care program
• Generally excludes infusion/network/ staffing
• Effective date:• July 19
• Stipulated penalties for non-compliance:• Financial• Exclusion
• Focus: • billing/training/ cost
report
Covered Individuals
• All full-time, part-time, per diem, administrative, and corporate employees
• Independent contractors
• Physician contractors• Does not include
janitorial staff
• More narrow definitions of “covered individuals” exists as it relates to certain training requirements
• CIA clearly establishes delegation of authority principles/ management accountability
General Compliance Training
• Effective date implementation
• All employees must receive compliance in the orientation process and annually thereafter
• Applies to contractors (via contract)
• Existing training is acceptable to meet requirement
• Compliance training tracking must be performed
• Managers will be required to certify compliance training has been provided to all staff in accordance with CIA and Company policy
Notification of CIA
• Within 60 days after executing the CIA, the Company will be required to summarize the contents of the CIA
• Published via intranet posting (already done)
• Company Newsletter article
• Notification to contractors (via letter)
• Summary will contain general action items, timetables, guidance, and commentary
• Follow up communication will be done through company
• Ongoing communications from management required supporting compliance efforts, applicable policies, and terms of the CIA
Notification and Attestation• All covered individuals will
be provided a copy of the compliance program description.
• All associates will be required to sign an attestation that they have received, read, and agree to adherence.
• All attestations must be collected and verified by line management and department heads ultimately to the CCO.
• Management will be required to gather and certify their operations comply with this requirement.
• New hires within 30 days.(Orientation).
• Program posting in each location (see posting policy).
Disciplinary System
• Require notification of compliance breaches to hotline
• Structured system (matrix)
• Penalty matches offense
• OIG to be notified of material violations of law
• OIG may inspect all records to validate compliance
• CCO must be notified of all disciplinary procedures resulting from breach of policy/ compliance program
Billing Training
• All field clinical managers, branch directors, etc
• Regional support personnel
• Regional management.• Limited back office
personnel• Clinical management
group
• Eight hour training requirement
• Appropriate billing procedures for all federal/state health care programs
• Must be completed within 120 days of execution
• Annual recertification
Training Requirements
• General training• All staff – 30 days and
annual• Contracts
• AVP’s and higher• 30 days and annual
• Cost report• RVP’s and higher• 30 days and annual
• Contracts• Sales personnel,
AVP’s and higher• 30 days and annual
• All training must be evidenced in personnel file and compliance training tracking system
Contract Training
• Contract group• Regional management• Senior management• Sales personnel• Four hour training
requirement• Must be completed
within 120 days of execution
• Annual recertification
• Stark• Anti-kickback• FMV• Contract how to• Federal participation
requirements
Cost Report Training
• Government financial services unit
• Corporate accounting• Senior management• Regional management• Eight hour requirement• Reimbursement
principles• Annual recertification
Note for all training:
• New employees must receive this training during orientation. All work performed prior to training must be reviewed.
Personal Expenses
• No personal expenses to be reimbursed by Medicare
• Management perks
• CCO to review travel and expense reports to monitor compliance
Contracts
• Require legal review of boilerplates
• Any contractual exceptions require law department review
• Referral source contracts to be scrutinized
• All operational contracts must be signed by AVP
• Independent Contractors• Compliance description• Certifications• Subject to review• OIG/GSA requirement
Medical Necessity
• Medical necessity policy reviews required
• Clinical review protocol• New hire review• Pre-bill release process• Quarterly audit tool
• Plan of care certification
• Internal on-site reviews are mandatory and will be provided in summary to OIG
• The Company will perform on-going review of clinical/operational policies
• Any internal changes to our policies must be disclosed to the OIG
• Offenses subject to compliance enforcement
Health Management
• FMV appraisals or valuations required of two pronged transactions
• Legal review of contracts
• Requirement for GHM personnel to abide by the Company’s compliance program
• Training requirements apply to GHM personnel
• Management attestations required
Items in Brief• OIG/GSA Checks• Excluded personnel-
treatment by the Company• Requirement to remove
from all dealings with federal programs
• Referrals for prosecution/ investigation• Identity of compliance
violators disclosed to OIG/DOJ
• Record retention• 5 year requirement on all
CIA materials• Cost relating to
implementation
• Implementation report• Training complete• Initiation of CIA processes
• OIG inspection authority• Complete access to verify
CIA compliance• Criminal background
checks• Performance
management• Compliance program/CIA
performance measured• Also applies to bonus
application
IRO - Billing Review• 30 Medicare certified home
health locations randomly selected each year.
• Statistical sampling of claims submitted in a 12 month period of time.
• Company receives credit for up to 15 internal investigations that employ the same or better sampling methodology.
• Errors will be repaid to the program.
• OIG retains discretion to require extrapolation to the universe of claims in the 12 month period.
• Extrapolation likely based on error rates.
• OIG can reduce or increase number of locations that can be selected each year (based upon performance or change in number of locations).
• Each on-site review will last @ one to two weeks.
• Dispute resolution occurs post audit.
IRO- Cost Report
• Cost report policies and procedures reviewed
• Allocation methodologies
• Home office cost allocation
• Allowable/non-allowable cost treatment
• Resolution of prior year audits
• Adherence to FI recommendations
• Internal controls present
• Company managers• Supporting documentation• Proper coding• Time study methodology• When in doubt…ask!
IRO- CIA Compliance
• Validate• CCO• Compliance committee• Disciplinary program and
records• Training• Certifications• Policies• Internal reviews• Hotline• Management
communication• OIG disclosures
• OIG/GSA checks.• Criminal background
checks.• Contract review.• OHM valuations.• Clinical review protocols.• Investigative reports.• Violations of CIA.• Etc……..
Annual Report
• Disclosures of overpayments
• Training material/certifications
• Hotline summary• Compliance program
information• IRO’s findings• Internal findings-billing• Clinical review process• CCO attestations
• Disciplinary actions pursuant to compliance violations
• Certifications from management
• Internal investigations• Non-compliance with
CIA• All material incidents of
non-compliance
