Proactive compliance plan will protect you from fraud charges
Monitoring and reporting are important components
One year after being found guilty of conspiring to defraud through a system of kickbacks for patient referrals and the filing of false claims that resulted in overpayments of more than $1 million from Medicare and Medicaid, six co-defendants were sentenced to a combination of almost seven years in federal prison and more than $526,000 in restitution payments.1
While the people involved in this case set out intentionally to defraud Medicare and Medicaid, home health managers need to stay alert and be aware of the gray areas of the rules that might put them at risk for allegations of fraud, says Denise Bonn, JD, counsel for Schmeltzer, Aptaker & Shepard, a law firm based in Washington, DC, with specialists in home health.
Every home health agency should have a comprehensive compliance plan that not only addresses issues related to fraud issues such as referrals but also to compliance with other federal regulations, she suggests.
"There are three types of compliance programs that you find in home health," says Chris Anderson, vice president of audit services and quality assurance and chief compliance officer for Gentiva Health Services, a Melville, NY-based company, which owns and manages more than 350 home health agencies nationwide.
"You have a mantelpiece program that looks nice but is never used," he says. The second type is found more often in hospital-owned agencies and has all the general elements of a compliance plan but is developed by the hospital and is not home health-specific, he adds. The third type of plan generates a close relationship between quality and compliance activities to promote an attitude of "do it right the first time," he says.
"I’m annoyed by lawyers who say if you have a compliance plan, you can avoid problems," Bonn says. "You need to make sure your plan represents a process that is in place and actively used to identify areas of noncompliance and address the problems," she says. Your plan will not help you avoid problems if it is not actively used, she adds.
Some steps to take to ensure a compliance plan that will work include:
- Include all regulations with which you must comply.
Medicare and Medicaid fraud is only one risk area for home health agencies, Bonn points out.
"I believe that OASIS [Outcome Assessment Information Set] and HIPAA [Health Insurance Portability and Accountability Act] requirements are more cumbersome and may create more opportunity for compliance problems for the home health clinician than any other area," she says. For this reason, make sure your staff training addresses these issues as well as other areas.
- Train your employees well.
For your first training session, it is fine to present an overview of the plan and discuss a wide range of issues, but be prepared to offer role- and issue-specific training in follow-up sessions, suggests Anderson. Marketing people need different information than home health clinicians or billing staff, so Gentiva has developed 35 different training sessions that address issues specific to different jobs, he adds.
- Designate a specific resource for compliance information.
While Gentiva has a designated compliance officer and staff members to oversee compliance issues, not all agencies may have the resources to devote employees to compliance, Anderson admits.
"It is important to designate someone as in charge of compliance issues, and that person needs to be independent of clinical or financial responsibilities," he says.
Need a compliance specialist?
The reason for independence is twofold, he says. "If an employee has a concern about billing practices, how can that employee feel comfortable going to the financial officer to suggest inappropriate activities in his or her department?" Anderson asks. "Also, you don’t want the perception of cover-up to occur if the person heading the compliance process is supervising the area in which the concern is raised."
Smaller agencies also might consider using a consultant or attorney to act as an outside compliance officer, he suggests. But be cautious.
It may not be wise to rely upon the same attorney who advises you on day-to-day business practices because the same perception of involvement in the area being questioned might exist, Anderson says.
For this reason, rely upon attorneys who specialize in compliance issues and use them only for oversight of this area, he adds.
- Set up monitoring and auditing systems.
Self-audits as well as external audits are important, but Anderson also suggests that agencies consider pre-billing audits on a regular basis.
"We have a group of clinicians that look at claims that are ready to submit for payment but have not yet been sent to Medicare," he says.
Sometimes, the group evaluates only one out of 10 claims for some locations, but if there has been a problem with a survey or if the location has not performed well on quarterly self-audits, it will review all claims, Anderson explains. "If we find problems with the claims, we use that information to plan further education for that location’s staff."
- Make it easy to report concerns.
Be sure you not only make it easy for employees to report potential compliance problems, but also make sure your staff understand that there are no repercussions for reporting concerns, Bonn says.
At Gentiva, employees, patients, and family members can contact the compliance department through a toll-free telephone number or by e-mail and maintain their anonymity, Anderson says.
"We assign every call a case number, and that person can use the case number in e-mails or calls to follow up," he says. "We also make a commitment to deal with or resolve every issue brought to our attention within 30 days."
When the hotline was first implemented, about 80% of the calls were related to human resource issues rather than just compliance issues, and most callers chose anonymity, Anderson says.
"It’s a sign of our program’s maturity that now all calls that come in are strictly compliance-related and that almost all callers give their names and contact information," he adds.
- Check your employees’ background carefully.
In addition to reference and license checks and visiting web sites of the Office of Inspector General (OIG) and the General Services Administration for employees who have been excluded from Medicare program participation upon hiring, Gentiva also runs periodic clearinghouse checks to catch any issues that were posted after hiring, Anderson adds.
"Sometimes, the OIG takes up to a year to post information, so the periodic checks are important," he says.
Don’t forget to follow through
- Address problems you identify.
If you discover that you are routinely billing for 10 physical therapy visits when you don’t make the full 10 visits, develop a corrective action plan and implement it, Bonn says.
It may sound obvious that you have to implement the plan, but she says too many agencies go through the exercise of developing a plan and then don’t follow through with it. "If a second audit shows that you are still making the same mistake, you cannot plead ignorance or simple mistake," she points out.
- Make sure your independent contractors follow your compliance plan.
A home health agency can be held accountable for a contractor’s actions, Anderson adds.
"We are responsible for managing the patient’s care, so we can’t have a contractor endanger a patient’s safety," he says.
"We are also billing Medicare based upon information from the contractor, so we have to know that the information is accurate," Anderson explains.
For those reasons, Gentiva’s contract with independent contractors states that the contractor also is bound by Gentiva’s compliance plan.
The most important thing any home health manager can do to avoid noncompliance allegations is to make a compliance plan part of the agency’s day-to-day operations, Anderson says.
"Even a small change in a billing procedure is reviewed by the compliance department," he says. "We want to make sure that the one change the billing department is proposing won’t cause problems in other areas."
[For more information about compliance issues, contact:
- Denise Bonn, JD, Counsel, Schmeltzer, Aptaker & Shepard, The Watergate, 2600 Virginia Ave. N.W., Suite 1000, Washington, DC 20037. Telephone: (202) 333-8800. Fax: (202) 337-6065. E-mail: [email protected]
- Chris Anderson, Vice President of Audit Services & Quality Assurance and Chief Compliance Officer, Gentiva Health Services, Three Huntington Quadrangle, Suite 2-S, Melville, NY 11747. Telephone: (631) 501-7000. E-mail: [email protected].]
Reference
1. United States v. DuPont, No. 00-05-009-01-15-CR-SW-3, United States District Court, Western District of Missouri (June 20, 2002).
One year after being found guilty of conspiring to defraud through a system of kickbacks for patient referrals and the filing of false claims that resulted in overpayments of more than $1 million from Medicare and Medicaid, six co-defendants were sentenced to a combination of almost seven years in federal prison and more than $526,000 in restitution payments.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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