The Carolinas Center Innovation and Excellence in Advanced Illness at End of Life

43rd Annual Hospice & Palliative Care Conference

“Emerging Trends in Serious Illness Management” September 10 - 12, 2019

The ABC’s of Compliance: Accountability, Best Practices and Consistency

Presenter:Kathleen A. Hessler, RN, JD, CHC, CHPCDirector, Compliance & Riskkhessler@Simione.com; (505) 239-8789

Presentation Summary

This session will identify the different areas of compliance under scrutiny by the government with an emphasis on payment compliance. Participants will gain a better understanding of the government’s current focus on auditing, investigating and collecting alleged overpayments. Learn how to implement sound compliance practices and consistency and we will also discuss how to approach communication with the MACs, ZPICs/UPICs, the OIG and the DOJ.

Objectives

• State the hot areas of focus by government contractors, auditors, and surveyors for hospice providers.

• Identify effective communication approaches in working with government oversight personnel.

• Learn strategies to implement accountability measures, best practices, and consistency in compliance.

• Three buckets of compliance with “spill-over” effect.1) HIPAA:

• Enforcement by Department of Health and Human Service’s (HHS) Office of Civil Rights(OCR).

2) Conditions of Participation (CoPs):• Enforcement by HHS Centers for Medicare and Medicaid

Services (CMS) and State survey agencies under contract with CMS or Accreditation organizations.

3) Billing and Payment: • CMS Hospice Provider Manuals; Enforcement by MACs, HHS

Office of Inspector General (OIG), Department of Justice (DOJ) & State Medicaid Fraud Units.

Three Buckets of Compliance

• The Health Insurance Portability and Accountability Act of 1996 (HIPAA): Legislation that provides data privacy and security provisions for safeguarding patient information. (Five Titles)

• In particular, healthcare providers must understand and be familiar with:

• Title II: HIPAA Administrative Simplification. It requires providers to implement secure electronic access to health data and to be in compliance with privacy regulations set forth by HHS.

• 2013 HIPAA Omnibus Rule modified HIPAA - HITECH - guidelines for Business Associates.

• Enforcement rule: increase in penalties.

Bucket 1: HIPAA

• All providers must appoint a HIPAA Compliance Officer• May have a Privacy Officer and a Security Officer.

• Implement Privacy & Security Policies/Procedures.

• Monitor compliance.

• Investigate, resolve and report breaches.

• Ensure Patient Rights.

• Ensure Administrative, Physical and Technical

Safeguards.

HIPAA Compliance Officer

• These regulations set-forth the requirements that providers must meet to be Medicare certified in order to receive Medicare or Medicaid payments.

• The focus is on patient care and coordination and management of that care, quality of services (QAPI), patient rights, and infection control--- to name a few. The CoPs are patient-centered and address the health and safety of the patient.

• The focus of state survey agencies or accreditation organizations is patient focused ---NOT payment centered.

Bucket 2: Conditions of Participation (COPs)

• Hospice CoPs: 2008

• Hospice CoPs: 2008.

• Updated Home Health CoPs: January 13, 2018• First major revisions in decades.• Interpretive Guidelines.

• Regulations versus Interpretive Guidelines.

Conditions of Participation (COPs)

• Hospice:

• Medicare Benefit Policy Manual - Chapter 9: Coverage of Hospice Services Under Hospital Insurance: 05-08-15.

• Medicare Claims Processing Manual: Chapter 11, Processing Hospice Claims: 12-01-17.

• For current manuals: Check website: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Download

• Home Health

• Medicare Benefit Policy Manual –Chapter 7-- Home Health Services: 02-24-17.

• Medicare Claims Processing Manual: Chapter 10--- Home Health Agency Billing: 01-05-2018.

There is spill over from CoPs to payment requirements (Examples)

Bucket 3: Compliance with Billing and Payment

• The home health and hospice benefits are costly and will continue to increase with increase of Medicare Beneficiaries.

• Overpayments and Fraud and abusive practices are real.• Mandates under the Patient Protection and Affordable Care Act (ACA).• Government Initiatives

• Medicare Strike Force - established in 2007 (OIG, DOJ, U.S. Attorneys, FBI, and local law enforcement).

• Example “2018 National Heath Care Fraud Takedown”.• From U.D. DOJ website:

• www.justice.gove/opa/pr/national-health-care-fraud-takedown-results-charges-against-601-individuals-responsible-over

• Government reports demonstrate patterns of potential or actual abusive practices.

• Government data analytics help determine who will be the target of an audit.• Data comparisons: state, regional, MAC jurisdiction, national.• PEPPER Data; claims, quality, and beneficiary data.

Why are Hospice Providers Targeted for Focused Audits?

Hospice-related Stats: Slide provided by OIG Attorney, June 2018

Hospice-related Stats

CY2016 CY2017

Criminal Actions 5 10

OI Civil/CMPL Actions 9 32

Office of Counsel to the Inspector General (OCIG) Civil/CMPL Actions 2 3

Total Civil/CMPL Actions 11 35

OI Expected Receivables $17,249,997.00 $129,364,826.00

OCIG Expected Receivables $126,919.00 $3,462,583.00

Total Expected Receivables $17,376,916.00 $132,827,409.00

Exclusions 4 10

Hospice Enforcement by the Numbers

Office of Inspector General: Reports on Hospice

• July 2019 U.S. DOH OIG Report: Safeguards Must Be Strengthened To Protect Medicare Hospice Beneficiaries From Harm (OEI-02-17-00021)

• July 2019 U.S. DOH OIG Report: Hospice Deficiencies Pose Risk to Medicare Beneficiaries (OEI-02-17-00020)

• June 2018 U.S. DOH OIG Report: Vulnerabilities in the Medicare Hospice Program Affect Quality Care and Program Integrity: An OIG Portfolio

• September 2016: Hospices Should Improve Their Election Statements and Certifications of Terminal Illness (OEI-02-10-00492)

• March 30, 2016: HHS OIG: Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care: 03/30/2016

OIG Vulnerabilities in the Medicare Hospice Programs

• OIG made a total of 15 recommendations to CMS. CMS concurred with five of these recommendations:• Develop other claims-based information and include it on Hospice Compare• Work with its partners, such as hospitals and caregiver groups, to make

available consumer-friendly information explaining the hospice benefit to beneficiaries and their families and caregivers.

• Analyze claims data to identify hospices that engage in practices or have characteristics that raise concerns.

• Take appropriate actions to follow up with hospices that engage in practices or have characteristics that raise concerns.

• Increase oversight of general inpatient claims and focus particularly on general inpatient care provided in SNFs, given the higher rate at which these stays were inappropriate.

• Implement a comprehensive prepayment review strategy to address lengthy general inpatient care stays so that beneficiaries do not have to endure unnecessarily long periods of time in which their pain and symptoms are not controlled.

Report: Hospice Deficiencies Pose Risks to Medicare Beneficiaries

•OIG stated objectives (see report):1. To determine the extent to which hospices have

deficiencies and the nature of these deficiencies.2. To determine the extent to which complaints are filed

against hospices and the nature of these complaints.3. To identify hospices that are poor performers and

describe their characteristics.

OIG: KEY TAKEAWAY: The majority of hospices had at least one deficiency in the quality of care they provide. It is essential that CMS take action to hold hospices accountable and protect beneficiaries and the program.

• Medicare Administrative Contractors (MACs).• Medicare and Medicaid audits (replace MICs).• Recovery Administrative Contractors (RACS) • Comprehensive Error Rate Testing (CERTS)• Supplemental Medical Review Contractors (SMRCs): ADRs

of claims billed and paid• Zone Integrity Program Contractors (ZPICS)-- Focus on

Fraud.• Unified Integrity Program Contractors (UPICS)

• Replacing the ZPIC, PSC and other.• Examples: Advance Med Corp ($76.8 million task order - first under

the UPIC). TriCenturion, Inc.; StrategicHealthSolutions LLC; Noridian Healthcare Solutions, LLC; IntegriGuard LLC d/b/a/ HMS Federal; Health Integrity, LLC.

Types of Government Audits

• MACs Medical Review Program• MACs must develop an annual Improper Payment

Reduction Strategy (IPRS) - required by CMS.• Data is analyzed by provider, services and

beneficiary.• Historical claims data.• Use of patterns/trends; high volume/cost and

change in frequency/outliers.• Comparative billing reports: state, regional and

national.• CMS Reports and other government reports

(OIG/GAO).

Targeted Probe and Educate (TPE)

• Once the MAC identifies your risk, claims review is initiated (i.e. high denial rates or unusual billing patterns).

• Validate issue.• Target and Probe of 20-40 claims.

• Selected Sample of 20-40.

• Initial request for records may be a smaller number of patients if agency has small census (but a total of 20-40 for round one is still applicable).

• Benchmarks established.

• One on one provider education.

• Providers with high error rates will continue to second and possibly third rounds.

TPE: What Agencies Need to Know

• Identify the contractor of the audit request (MAC, ZPIC, UPIC, OIG…).

• Do not panic…

• Do not ignore the letter or let the letter sit on your desk -----or any desk! These are time sensitive…

• Take immediate action:

• Notify your compliance officer.• Consider engaging legal counsel and outside consulting

firm to assist …with record organization….other.• Organize records for ease of auditor review; submit

timely.

Actions to take when you receive notice of an audit or a clinical record request

1. Redeterminations Conducted by the MAC.

2. Reconsiderations (Qualified Independent Contractors—QICs) Second level of appeal filed to QIC.

3. Administrative Law Judge (ALJ).

4. Medicare Appeals Council (DHHS).

5. Judicial Review ---U.S. District Court.

Provider Appeal Rights

• Establish a formal compliance program with the seven elements as set forth by the OIG guidelines 1998-99 (see next slide);

• Frequent the HHS OIG website to review any new Hospice Corporate Integrity Agreements (CIA)—review and study these as a source of information for best practices.

• https://oig.hhs.gov/compliance/corporate-integrity-agreements/index.asp

Where to Start with Payment Compliance

OIG Seven Elements of a Compliance Program

1. Policy/Procedure/Written Code.

2. Compliance Officer/Committee.

3. Training/Education.

4. Communications/Anonymous.

5. Auditing Monitoring ---Internal & External monitoring by experts (Attorney Client Privileges issues/ethics).

6. Disciplinary Measures.

7. Disclosure /Timely Investigations and Reporting.

• Create a dedicated Compliance Team

• Appoint Compliance Officer/Manager who has requisite education.

• For multi-location providers, compliance demands mean having leaders at the corporate offices and agency level.

• Ensure proper policies and procedures are in place.

• Educate clinical staff on how their documentation forms the basis for billing and payment

• Provide ongoing education and training in documentation on eligibility and technical billing requirements-- Consider peer review of clinical records.

• Conduct a forms review.

• Clinical staff must understand the regulations and clinical documentation payment requirements.

Executives & Employee Accountability

• Governing Board involvement and knowledge.

• Executive Team involvement and knowledge: CEO, COO, CFO, CCO, CNO, CIO, other.

• Marketing Team.

• Human Resources.

• Clinical Management and staff clinicians/care providers.

• Revenue Cycle and Billing personnel.

• Other (see recent CIA requirements).

Accountability

• Educate Governing Board & Executive Team• Private or Public: The government is looking to provider

governing Boards for effective oversight of healthcare providers ---and to monitor company quality and compliance.

• See “Practical Guidance for Health Care Governing Boards on Compliance Oversight” on OIG website.

• See also: “A toolkit for Health Care Board.

• Go to: www.oig/hhs/gov for additional resources and guidance for compliance related issues.

Best Practices & Managing Risk

• Clinical/Documentation and QAPI & Compliance Committees• Practical hands-on documentation (training and practice) consistent with

regulations.

• Education on payment requirements.

• Physicians, nurses/practitioners, therapists/chaplains, MSW.

• QAPI/Compliance: Pre-Bill auditing and monitoring for eligibility/technical documentation requirements.

• FORMS Review for technical billing issues.

• Revenue Cycle and Billing• EMR education/Billing education and implementation of pre-bill edits.

• Routine pre-bill reviews/audits of final claim ready to bill.

Best Practices & Managing Risk

Conduct pre-bill audits and use data analytics to track billing patterns

• Review PEPPER reports and other current EMR reports that provide dashboard measures and patterns, percentages.

• Self-monitoring reduces the likelihood of abusive or reckless habits and potential overpayments.

• Consider external consultants for quarterly or annual audit & education.

Identify the billing and payment issues under scrutiny and develop an audit plan

• Develop quarterly and annual audit plans for oversight and to focus on identified problem areas.

• Distinguish compliance audits and QAPI activities.

Frequent CMS/OIG/DOJ websites and use resources such as state and national provider associations and external expert consultants.

Best Practices & Managing Risk

• Human Resources: • On hire & monthly: OIG Exclusion checks.

• Code of Conduct/Standards of Ethics: introduce on hire and signed by employees, independent contractors; vendor education.

• Annual employee attestation (and exit interview attestation) that employee is not aware of non-compliance with policy or violations of the law.

• Set up expectation of exit interview on hire.

• Disciplinary Practices.

• Access to EMR and settings—determine who and implement oversight.

• Marketing & Referral Sources• Training and education.

• Role playing; case studies; use agendas & sign-in sheets.

Best Practices & Managing Risk

Compliance is a collaborative effort across your organization, departments, and provider locations.

Compliance requires consistency and continuous oversight of practices.

Compliance is Everyone’s Job!

• Department of Justice:

www.justice.gov/criminal-fraud/page/file/937501/download

U.S. Department of Justice, Criminal Division, Fraud Section:• Guidance Document updated April 2019 (previous Feb.

2017): • Evaluation of Corporate Compliance Programs.

• HHS/OIG Website: www.oig.hhs.gov• See Current Hospice Reports• HCCA/OIG Document March 2017.

• Measuring Compliance Effectiveness.

Also see: https://oig.hhs.gov/compliance/compliance-resource-portal/

Compliance Resources

QUESTIONS

Education Purposes

This presentation is for educational purposes only and should not be construed as providing legal advice.

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Kathleen A. Hessler, RN, JD, CHC, CHPC Director, Compliance & Risk khessler@simione.com or 505.239.8789