Administration turns up the heat on home care
The regulatory environment has changed
Home care providers have been given an unpleasant jolt in recent months as the Clinton administration has expanded Operation Restore Trust and has called for tighter measures to prevent Medicare fraud.
Federal officials have considered some drastic changes, including the widely criticized proposal to redefine the homebound requirement.
Some home care industry advocates say the intense scrutiny is unfair because the home care industry despite its recent growth surge still is only a small piece of the health care spending pie. (See story on why federal officials are cracking down on home care agencies, p. 106.)
But like it or not, the home care regulatory environment has changed, and all agencies that hope to retain Medicare certification need to know how to prevent employees from unwittingly committing fraud and abuse.
An Atlanta-based company developed a compliance program in 1994 and was among the first to voluntarily do so. The comprehensive program covers every aspect of Medicare requirements and has a strong focus on employee training, says Chris Anderson, vice president of compliance and quality improvement of Housecall Medical Resources in Atlanta. The national company has facilities across the country that provide home health care, infusion services, durable medical equipment and oxygen, hospice, and management services.
"We instituted the compliance program as a proactive step because we saw the scrutiny increasing within the industry, and with our plans for growth, we thought it was paramount that we institute a compliance program to meet new requirements within Medicare," Anderson explains.
Anderson suggests home care educators start by teaching their staff about the seven Federal Sentencing Guidelines that were written for all companies that contract with the federal government, including defense contractors, banking institutions, the health care industry, and others.
The guidelines are as follows:
1. Compliance standards:
"That is an understanding of what laws are in place that govern your industry," Anderson says.
This guideline is not designed specifically for home care, so each provider will have to customize it to fit its needs.
Anderson suggests education managers begin by including Medicare fraud and abuse training in the orientation of each new employee.
"Every employee that goes through the training signs a form that says they have received compliance training, and those records are sent to my office," Anderson says. "I have more than 7,000 signatures on file of employees who have been trained."
At Housecall’s agencies, the very first requirement for each employee is that he or she receives compliance training. The training includes explanations of what constitutes a false claim and what Medicare means by the terms fraud and abuse.
Housecall and other companies teach staff how it’s very important that each employee take responsibility for making sure all Medicare guidelines are met. Then, it’s the company’s responsibility to carefully check the documentation and work of each employee, says Mary Elizabeth Derwin, JD, MS, RN, CNAA, a staff attorney for the Visiting Nurse Association in Detroit.
"First, look at the claims they submit. There has to be a procedure in place that reconciles the claims with the actual documentation for visits," Derwin says. "What is written on the bill has to be consistent with what they have documented."
Next, Derwin advises, make sure the amount of service and kind of service is consistent with the patient’s needs and was authorized by the physician.
The Kennedy-Kassebaum bill, also called the Health Insurance Reform Act of 1996, has put physicians’ feet to the fire by setting up civil penalties for doctors who send patients to home care facilities that defraud Medicare. "They put the burden on physicians to monitor a home health group," Derwin says. "A lot of physicians and agencies aren’t aware of the new law."
This bill will erode the standard physician-home care provider trust that the two groups have enjoyed for years, she adds.
"As soon as physicians find out about the law, they’re going to be very hesitant to sign those plans of care, so home health agencies are going to have to be very careful and make sure that what they put on the plan of care is consistent with the patient’s elements for certification," Derwin emphasizes.
"A physician who knowingly certifies a plan of care for a beneficiary who does not meet requirements of certification is subject to civil money penalties from $5,000 to three times the amount of the home health agency bill," Derwin adds.
2. Program oversight:
This provision requires companies to establish a compliance program at the senior levels of the company to ensure that top officials are not just paying lip service to compliance.
Housecall combined compliance with quality improvement, and Anderson reports directly to the company’s president and has indirect supervision by the board of directors. "The government’s rationale is that if you set this up at a very high level, then it will have a trickle down effect," Anderson explains.
"They don’t like for you to have a compliance program within the operating unit," he adds. "They think it’s a strike against you if you do because they see that as a potential conflict of interest."
So agency’s should set up their compliance program at the executive level.
3. Employee training:
Besides the mandatory orientation training on compliance, all Housecall employees receive compliance training throughout the year.
"We do a minimum of quarterly fraud and abuse updates with the staff," Anderson says. "Other training programs are developed with compliance in mind."
Anderson gives an example of the company’s training on how employees follow the 485 and billing process. "If we’re talking about billing, we go over the False Claims Act and how it’s not only that you follow processes," he says.
Watch for inappropriate care
Employees are taught to keep in mind that if they submit a 485 that’s inappropriate for the federal government, then it could be a violation of the False Claims Act.
Union Hospital Home Health in Dover, OH, teaches staff about Medicare requirements and gives employees examples of types of care that could be considered inappropriate, says Deborah Albaugh, RN, BSN, home health director.
"Say a patient needs wound care, but the patient can’t meet [his or her own] daily needs, and you take the patient in care even when there’s no hope the wound will heal in the home environment, then that’s a factor to consider," Albaugh says.
"Anytime we have a patient that is questionable to appropriateness, then we’ll have a social worker go out and make a visit. And we have a written policy on how to terminate care to inappropriate patients," Albaugh adds.
4. Delegation of authority:
Each company is responsible for making sure none of its top management and none of the employees will commit illegal acts, Anderson says.
"What we do is make sure the proper background checks are being performed and monitored to make sure the people we do have in place are the appropriate people to have in place," he adds.
The Health Insurance Portability & Accounta bi lity Act of 1996, which went into effect this year, makes this strategy crucial. One of its provisions is that if an agency hires someone who has been convicted of Medicare fraud, then that employee could jeopardize the entire company.
"They could pull your ability to provide care to the Medicare population," Anderson says. "It does require background checks and screens on anyone in a management position."
Also, Congress has been considering some legislation that would require background checks on all employees.
The federal government has made it clear that "every single employee of an agency has an obligation to prevent Medicare fraud and abuse, so this must be an agencywide effort," says Elizabeth Hogue, a Burtonsville, MD, attorney who specializes in health law.
"The key to it is education and training, and I can’t emphasize that enough," Hogue adds.
5. Monitoring, auditing, and reporting systems:
This requirement is designed to make sure each company has the proper internal controls in place, including routine audit operations, Anderson says.
"The compliance officer must have access to all information," he adds.
Housecall’s compliance program meets this requirement, but at the same time, the company doesn’t want to make employees fear compliance actions, Anderson says. "We want to stay away from the dogmatic type of atmosphere where people are upset that I’m calling them."
Instead, the company focuses more on training and involving all employees in the compliance monitoring. For example, every employee is given a phone number to Anderson’s office where they can call at any time to discuss a concern or complaint. He will return their calls within 24 hours.
"A lot of times, people just have questions about things, and they just don’t understand a policy," Anderson says. "If we can enlighten them, then that eliminates an employee’s concern that could grow and fester in an office."
Patients also can call Anderson, and they sometimes do.
Then at the corporate level, Housecall has surveys where everything that’s written on a chart is verified to be accurate. Also, the homebound status of Medicare patients is monitored.
Union Hospital Home Health has managers make unannounced visits to patients’ homes, Albaugh says. This is a good way to monitor that the field staff is in the home at the scheduled time. "Almost always the nurse is there, and if the nurse is not, it’s because of a delay," Albaugh says.
Housecall keeps track of all new state and federal legislation that could affect home health care. When a new issue arises, it’s reported to the company’s executives and senior managers.
6. Enforcement and discipline:
It’s very important to consistently administer enforcement actions, Anderson says.
"If things change in the industry, we need to quickly adapt our policies to enforce those changes," he adds.
Housecall has a policy, for example, that calls for immediate dismissal if there’s a falsification on some type of document.
7. Response and corrective action:
Part of Housecall’s corrective action is to make sure any problems that occur are fixed. The company monitors progress every 30, 60, or 90 days to make sure the problem is resolved, Anderson says.
"Some things are not necessarily a quick fix, but you have to make sure you are adhering to the policy and that you can identify that progress in writing," he explains.
"The goal of corrective action is if there’s an issue, you have to put proper things in place to make sure it doesn’t happen again," Anderson says.
[Editor’s note: Elizabeth Hogue has created a book, Preventing Fraud and Abuse: A Guide for Medicare and Medicaid Providers. It can be purchased for $20, plus $5 shipping and handling by writing her at 15118 Liberty Grove, Burtonsville, MD 20866, or by sending a faxed purchase order to (301) 421-1699. Also, Hogue creates compliance plans for home health companies. For more information, call Hogue at (301) 421-0143.]
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