The Cost of Non-Compliance: Is it in Your Budget?

The Cost of Noncompliance: Is it in Your Budget?

Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 1

HARMONY UNIVERSITYThe Provider Unit of

Harmony Healthcare International, Inc. (HHI)Presented by:

Keri A. Hart, MS-CCC/SLP, RAC-CT, CHHRP-QTVice President of Clinical Operations/Education and Training

Harmony Healthcare International, Inc. 2

About Keri

Keri Hart, MS-CCC, SLP, RAC-CT, CHHRP-QT

Keri Hart is the Vice President Clinical Operations/Education and Training at Harmony Healthcare International, (HHI) an industry leader in Long Term Care consulting.

Over 25 Years Experience in Long-term Care

Rehabilitation Management

MDS

Follow Me! @CHHRPHart

Copyright © 2014 All Rights Reserved

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The Cost of Noncompliance: Is it in Your Budget?

Disclosure: The planners and presenters of this education activity have no relationship with commercial entities or conflicts of interest to disclose

Planners:

Kris Mastrangelo, OTR/L, MBA, LNHA

Elisa Bovee, MS, OTR/L

Diane Buckley, BSN, RN, RAC-CT

Keri Hart, MS-CCC/SLP, RAC-CT, CHHRP-QT

Presenter: Keri Hart, MS-CCC/SLP, RAC-CT, CHHRP-QT

Copyright © 2014 All Rights Reserved

The Affordable Care Act

The Affordable Care Act (ACA) was passed by Congress and then signed into law by the President on March 23, 2010

On June 28, 2012 the Supreme Court rendered a final decision to uphold the health care law

ACA mandates compliance programs for all nursing homes by March 23, 2013


SNF Regulations

Regulations not released to date however ACA is in effect

Current Guidance:OIG Compliance Guidance (2000)

OIG Supplemental Compliance Guidance (2008)

OIG Compliance 101 and Provider Education


Fraud, Waste and Abuse

The Government Accountability Office has designated Medicare as a program at high risk for fraud, waste, and abuse

Payments to skilled nursing facilities (SNFs) have been identified as vulnerable to abuse

In 2012 the Office of Inspector General (OIG) found that approximately 25% of SNF claims were billed in error


2014 SNF PEPPER User’s Guide

“Beginning in 2013, SNFs are required to have a compliance program”

“As part of a compliance program, a SNF should conduct regular audits to ensure services provided are necessary and that charges for Medicare services are correctly documented and billed”


The 7 elements of a SNF Compliance Program


Seven Elements of Compliance

Policies and Procedures

Reporting and Investigating

Education and Training

Prevention and Response

Auditing and Monitoring

Responsibility/Oversight of Compliance Officer/Committee

Enforcement, Discipline and Incentives


PREPARE

Risk Areas

Risk areas per OIG include:Quality of care and residents’ rights

Employee screening

Vendor relationships

Billing and cost reporting

Record keeping and documentation

This list of risk areas is not exhaustive, nor all encompassing

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Monitors compliance activities

Manages, develops and implements corrective plan

Reports directly to the top

Authority and resources to complete job



High-level executive to oversee compliance program

Credible

Demonstrates integrity

Makes it real

Prioritizes

No vested interest (e.g. Revenue, Outcomes)


Medicare Fraud redefined


Fraud

Knowingly means knew or should have known

“Knowingly” submitting false statements or making misrepresentations of fact to obtain a federal health care payment for which no entitlement would otherwise exist

Knowingly billing for services at a level of complexity higher than the service actually provided or documented in the medical record


Abuse

Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare Program

Abuse includes any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and priced fairly


What do You Know?

Facilities must have an effective compliance program that:

Prevents

Detects

Deters

Not knowing is no longer an excuse for Fraud and Abuse


The Cost of Non-Compliance


Cost of Compliance Program

An effective compliance program may require a reallocation of existing resources, the long term benefits of establishing a compliance program significantly outweigh the initial costs


Cost of Non-Compliance

Criminal sanctions may be mitigated by an effective compliance program

$305,072 and was required to hire a full-time physician or NP after it was found to have sub-standard pressure ulcer treatment and prevention, incontinence care, pain management, nutrition, weight monitoring, infection control, and diabetic care



$1.5 Million for submitting claims to Medicare and Medicaid for services provided by an unlicensed speech therapist

$13 Million Dollars for incentives for productivity and providing care not supported by documentation



OIG alleged that a SNF submitted claims to Medicare for physical therapy services that were improperly documented by a physical therapist formerly employed by SNF. Documentation did not meet certain progress report requirements.



A SNF in Texas, agreed to pay $1,139,789.65 for allegedly violating the Civil Monetary Penalties Law. OIG alleged that they billed for post hospital extended care services furnished at the SNF using certifications and re-certifications that did not meet applicable Medicare criteria.



A New York SNF, agreed to pay $42,556.29 for allegedly violating the Civil Monetary Penalties Law. OIG alleged that the SNF submitted claims for occupational therapy services provided concurrently but billed as if provided individually.


OIG Exclusion List

After it self-disclosed conduct to OIG, a SNF in Arkansas, agreed to pay $117,748.32 for allegedly violating the Civil Monetary Penalties Law. OIG alleged that the SNF employed 2 individuals that it knew or should have known were excluded from participation in Federal health care programs.


Whistle Blowers

Increase in whistleblowing :

752 whistleblower suits in FY 2013

$2.9 Billion for the government

$345 Million for whistleblowers


Whistle Blowers

Nursing home paid $28.1 Million, whistleblower received $400k

Nursing home and therapy company paid $48 Million whistleblower award up to $12 million

Nursing home and its owners paid $700k whistleblowers received $122,500

Therapy company to pay $30 million whistleblower award $5.7 million


Benefits of Compliance

Formulation of effective internal controls to ensure compliance with statutes, regulations and rules

Demonstration to employees and the community of the commitment to responsible corporate conduct

Obtain an accurate assessment of employee and contractor behavior

Identifying and preventing unlawful and unethical behavior

Prompt reaction to employees’ operational compliance concerns and effectively target resources to address those concerns



Improvement in the quality, efficiency, and consistency of providing services

Establish a mechanism to encourage employees to report potential problems and allow for appropriate internal inquiry and corrective action

Centralized source for distributing information on health care statutes, regulations and other program directives

Improve internal communications

Prompt and thorough investigation of alleged misconduct


Compliance Program

“Superficial efforts or programs that are hastily constructed and implemented without a long term commitment to a culture of compliance likely will be ineffective and may expose the nursing facility to greater liability than if it had no program at all”



Early detection and reporting, minimizing loss to the Government from false claims, and thereby reducing the nursing facility’s exposure to civil damages and penalties, criminal sanctions, and administrative remedies


Risk Assessment: the Key to Success


Risk Assessment

Identify

Measure

Prioritize


Risk Assessment

Determine risk areas

Prioritize on severity, likelihood and impact

Ongoing assessment

Best practice

Changes in PolicyMedicare

MDS


Annual Compliance Work Plan

Compliance Officer’s Role is Monitoring compliance activities

Focused:Past issues

Regional Issues

Policy Changes

OIG Work Plan

Historic Medicare Denials


Practical Application

Based on the facility’s risk assessment:

What are your facility goals?

What needs to be accomplished to achieve these goals?

What are your barriers to achieving these goals?

How do you communicate your goals?


Creating and Enforcing Policies and Procedures



Policy: Statement of Approach

Procedures: Steps to Achieve



Separate policies for compliance

No Retaliation PolicyMay not retaliate against for informing management about an activity which that person believes to be fraudulent, dishonest or illegal with the intent or effect of adversely affecting the terms or conditions of their employment

Including, but not limited to, threats of physical harm, loss of job, punitive work assignments, or impact on salary or fees…


Reporting and Investigating

Process should include:Includes an Anonymous System

Non-Retaliation Philosophy to report concerns

Investigate all concerns

Investigator/Auditor should have a specialty in subject matter



Code of Conduct provides expectationsPractical Guidance

Commitment to Compliance

Clear Language

Accountability



Reinforced by best practice

Policy and procedures for:MDS Completion

Triple Check

Therapy Documentation completion

All risk areas identified

Accountability



What is the facility process for areas of concern?

What is the facility procedure?

What is the potential risk without a formalized procedure?



What is the facility’s team response to areas of concern?

Is the Administrator aware of the teams barriers to addressing the identified concern?

What is the root cause?


Benefits of Education and Training


Education and Training

Compliance process

Risk AreasADL

Therapy Documentation

Medicare requirements

Easy to understand

Focused



What are the facility’s educational needs?

Have we completed follow-up auditing after education?

How will you measure the effectiveness of the education provided?


Prevention and Response

Respond to reports

Root cause analysis

Provide education in risk areas

Develop policy and procedure to prevent non-compliance



Do MDS Coordinators and Therapists know the new COT rules effective October 1st?

Does the Interdisciplinary Team know the changes in the Medicare Benefit Policy Manual Chapter 8 ”Coverage of Extended Care (SNF) Services Under Hospital Insurance” with implementation on January 7th 2014?

Have you provided education related to the reasons for Medicare denials?

Can you prove they were educated?


Benefits of Auditing and Monitoring



MonitoringCommon Management Tool

Determines how effective the controls are

Helps facility or corporate know what is happening in the field

Day to day reviews

Includes self reviews and peer reviews



AuditingCompleted by someone with no vested interest

Formalized Approach

Established approachMethodology

Effectiveness of correction

Scientific sampling when completing for corrective plan



The integrity of the Audit is based on the relationship of the auditor

No vested interest in outcome of the audit



How are you selecting charts and claims to audit?

Are you monitoring trends?

Are you auditing the monitor?

What are you doing about your findings?


Keys to Success

Develop a plan

Back to basics

Integrate the value of compliance

Walk the Walk and Talk the Talk

Implement and follow Policy and Procedure

Value the chart audit process

Value education

Compliance IS the foundation for Accurate Reimbursement


Questions/Answers

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www.Harmony-Healthcare.com

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The Cost of Non-Compliance: Is it in Your Budget?

Healthcare

Transcript of The Cost of Non-Compliance: Is it in Your Budget?