Compliance plans target discharge planning
Discharge planning considered 'risk area'
Federal investigators have made hospital discharge planning a key target of their wide-ranging fraud investigations, judging by two significant model compliance plans released this year by the federal Department of Health and Human Services' Office of the Inspector General (OIG).
In its hospitals' model compliance guidance, for example, the OIG lists two "risk areas" for fraud that apply directly to case managers:
· Billing for discharge in lieu of transfer.
"Under the Medicare regulations, when a prospective payment system (PPS) hospital transfers a patient to another PPS hospital, only the hospital to which the patient was transferred may charge the full DRG; the transferring hospital should charge Medicare only a per diem amount," according to the model plan.
· Patients' freedom of choice.
"This area of concern is particularly important for hospital discharge planners referring patients to home health agencies, DME [durable medical equipment] suppliers, or long-term care and rehabilitation providers," the plan states.
The concern is that hospitals may refer patients directly to their own affiliated agencies without informing them that they're free to choose a different provider. (See "Feds go after discharge planner over improper home health referrals," Hospital Case Management, November 1997, p. 193.)
"It really depends on what the hospital's relationships are with the vendors and whether they have an ownership interest," says Vicki Myckowiak, JD, a Detroit-based attorney specializing in health care compliance issues. "You could end up with some self-referral issues, or some kickback issues."
In a section of the hospital model plan titled "Anti-kickback and self-referral concerns," the OIG says a hospital's policies and procedures should provide that:
· all of the hospital's contracts and arrangements with referral sources comply with all applicable statutes and regulations;
· the hospital does not submit or cause to be submitted to Medicare claims for patients who were referred to the hospital in exchange for financial incentives. Schemes to induce referrals may violate the anti-kickback statute, Stark physician self-referral law, or similar federal or state statutes or regulations. Possible penalties include fines up to $25,000 and even jail time.
The home health model plan, released in August, reiterates the OIG's concerns over anti-kickback violations. One example cited in the home health plan of an arrangement that could run afoul of the anti-kickback statute is when a home health agency "provides nursing or administrative services for free or below fair market value to physicians, hospitals, and other potential referral sources."
Myckowiak notes that the OIG and Congress have become very sensitive to self-referral issues, following legislation that prevented physicians from referring work to laboratories in which they hold an ownership interest. "The OIG and Congress believed that if you're referring to a lab in which you have an ownership interest, you're much more likely to order laboratory services," Myckowiak says. "Now they've expanded it to other designated health services, which include things like physical therapy."
For more information, contact Vicki Myckowiak, JD, law firm of Steinberg, O'Connor, & Burns, 1724 Ford Building, Detroit, MI 48226-3901. Telephone: (313) 963-1002.
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