Emerging Issues in Home Care2000 and Beyond

Chris Anderson

Gentiva Health Services

Melville, New York

Phil Bradley

Long, Aldridge & Norman LLP

Atlanta, Georgia

Emerging Issues

HIPAA

Privacy, Security, Communications, & Cultural Behaviors

PPS

Billing, Billing, Billing

Impact to cost reporting

False Claims

Is it a new ball game?

Patient Inducement

New restrictions, advisory opinions

HIPAA

Privacy, Security, Communications, & Cultural Behaviors

PPS

Billing, Billing, Billing

Impact to cost reporting

False Claims

Is it a new ball game?

Patient Inducement

New restrictions, advisory opinions

Corporate Integrity Agreements

If you don’t have….

Credit Balance Issues

Self- Disclosure

Or self suicide?

Corporate Integrity Agreements

If you don’t have….

Credit Balance Issues

Self- Disclosure

Or self suicide?

Who is affected by HIPAA?

All health care organizations that process health data and/or transmit data electronically must comply

Health plans, payors and clearinghouses that process health data must comply

All health care providers electing to conduct covered transactions electronically must comply

Employers, public health authorities, life insurers, medical billing agencies, information system vendors, service organizations and others entities if conducting any of the covered transactions must comply

All health care organizations that process health data and/or transmit data electronically must comply

Health plans, payors and clearinghouses that process health data must comply

All health care providers electing to conduct covered transactions electronically must comply

Employers, public health authorities, life insurers, medical billing agencies, information system vendors, service organizations and others entities if conducting any of the covered transactions must comply

What transactions are covered?

Administrative and financial health care transactions: Health claims & encounter data

Health claims attachments

Enrollment/ disenrollment in a health plan

Health plan eligibility

Health care payment and remittance advice

Health plan premium payments

Injury reports

Health claim status

Referral certifications and authorizations

Administrative and financial health care transactions: Health claims & encounter data

Health claims attachments

Enrollment/ disenrollment in a health plan

Health plan eligibility

Health care payment and remittance advice

Health plan premium payments

Injury reports

Health claim status

Referral certifications and authorizations

Compliance Deadlines

24 months from the effective date of the final rules

Effective date is usually 60 days following publication of the rule

Anticipate all rules to be published by the end of 2000 – Compliance necessary by early 2003

DHHS Schedule for Publication

Transaction and Code sets – published

Other Standards -- Final Rule Publication dates unclear but expected by end of summer 2000

24 months from the effective date of the final rules

Effective date is usually 60 days following publication of the rule

Anticipate all rules to be published by the end of 2000 – Compliance necessary by early 2003

DHHS Schedule for Publication

Transaction and Code sets – published

Other Standards -- Final Rule Publication dates unclear but expected by end of summer 2000

Penalties for Noncompliance

Severe Civil and Criminal Penalties for Noncompliance

Fines up to $25K for multiple violations of the same standard in a calendar year

Fines of up to $250K and/or imprisonment up to 10 years for knowing misuse of individually identifiable health information

Severe Civil and Criminal Penalties for Noncompliance

Fines up to $25K for multiple violations of the same standard in a calendar year

Fines of up to $250K and/or imprisonment up to 10 years for knowing misuse of individually identifiable health information

Costs

Compliance will be very costly and must be budgeted

It has been estimated that compliance with HIPAA will consume 33 cents of every health care dollar between now and 2003

Hardware & Software Costs Encryption, Privacy, Monitoring Systems

Operational Costs

Teaching and Training

Changing Behaviors

Monitoring of access and usage

Compliance will be very costly and must be budgeted

It has been estimated that compliance with HIPAA will consume 33 cents of every health care dollar between now and 2003

Hardware & Software Costs Encryption, Privacy, Monitoring Systems

Operational Costs

Teaching and Training

Changing Behaviors

Monitoring of access and usage

HIPAA Compliance Preparation

Raise organizational awareness

Create a leadership plan to oversee the development and execution of appropriate plan

Develop a systematic plan of evaluation and action related to compliance with the regulations

Dedicate resources to the implementation of a strategic plan to address the requirements of the legislation

Discuss the implications of the regulations and create a compliance plan

Develop a plan to educate employees regarding the new regulations

Marketing/PR strategy to address patient/ client/ customer concerns

Raise organizational awareness

Create a leadership plan to oversee the development and execution of appropriate plan

Develop a systematic plan of evaluation and action related to compliance with the regulations

Dedicate resources to the implementation of a strategic plan to address the requirements of the legislation

Discuss the implications of the regulations and create a compliance plan

Develop a plan to educate employees regarding the new regulations

Marketing/PR strategy to address patient/ client/ customer concerns

HIPAA Compliance Preparation (Continued)

Engage outside consultants or vendors if necessary

Review and assess existing systems, policies and procedures

Develop and revise policies and procedures

Commence modification of existing systems to comply with the regulations

Examine contracts with 3rd parties to determine compliance

Review impact on relationships with customers, clients, etc.

Review insurance policies to determine current/future coverage for breaches of confidentiality

Address potential legal liability and risk management issues

Engage outside consultants or vendors if necessary

Review and assess existing systems, policies and procedures

Develop and revise policies and procedures

Commence modification of existing systems to comply with the regulations

Examine contracts with 3rd parties to determine compliance

Review impact on relationships with customers, clients, etc.

Review insurance policies to determine current/future coverage for breaches of confidentiality

Address potential legal liability and risk management issues

Prospective Payment System

Fraud and abuse elements

Upcoding

False Claims

Utilization standards

Cost report compliance

Patient Dumping Issues

• Learn from the hospital DRG system (400 + CIA’s)

Fraud and abuse elements

Upcoding

False Claims

Utilization standards

Cost report compliance

Patient Dumping Issues

• Learn from the hospital DRG system (400 + CIA’s)

Audit Goals for PPS

More than ever audits will be driven from a clinical standpoint

Through out the traditional analysis approach

No longer talking about straight technical issues

Billing systems will play an integral role in audit approach

More than ever audits will be driven from a clinical standpoint

Through out the traditional analysis approach

No longer talking about straight technical issues

Billing systems will play an integral role in audit approach

Prospective auditing (Pre-bill release)

Oasis

HHRG

Grouper

Utilization Standards

Care Protocols

90 day window of opportunity for full implementation of billing filters at the FI’s.

Prospective auditing (Pre-bill release)

Oasis

HHRG

Grouper

Utilization Standards

Care Protocols

90 day window of opportunity for full implementation of billing filters at the FI’s.

PPS Compliance Preparation

No existing best practices

Learn and not learn from hospital experience.

Training is key

Billing Training Including:

• Coding

• Oasis

• Medicare Coverage

• HHRG

• System Gaming

All clinical- billing staff

No existing best practices

Learn and not learn from hospital experience.

Training is key

Billing Training Including:

• Coding

• Oasis

• Medicare Coverage

• HHRG

• System Gaming

All clinical- billing staff

Risks:

Patient Complaints

Caregiver Complaints

Utilization is the driver

Communication plan

Hotline response system and its tie to compliance

System analysis

RAP/Claim release process

Risks:

Patient Complaints

Caregiver Complaints

Utilization is the driver

Communication plan

Hotline response system and its tie to compliance

System analysis

RAP/Claim release process

PPS Compliance Preparation

Operational difficulties

RAP & Cash Flow versus Compliance

Physician orders- Verbal start of care orders

Significant drops in utilization- impact

Risks

False Claims

Medical Review

FI- CERT Program

Trending analysis- ORT

Operational difficulties

RAP & Cash Flow versus Compliance

Physician orders- Verbal start of care orders

Significant drops in utilization- impact

Risks

False Claims

Medical Review

FI- CERT Program

Trending analysis- ORT

False Claims

Civil Monetary Penalties Risks

• Billing System Changes (PPS)

• Stronger intervention by MFCU’s

• CERT Program

New Requirements have no bearing on the establishment of CIA’s

Effect on Qui Tam actions unknown

Age old issue- The Rules in Conflict – COP’s, Kickback, False Claims, etc.

Civil Monetary Penalties Risks

• Billing System Changes (PPS)

• Stronger intervention by MFCU’s

• CERT Program

New Requirements have no bearing on the establishment of CIA’s

Effect on Qui Tam actions unknown

Age old issue- The Rules in Conflict – COP’s, Kickback, False Claims, etc.

Keys to Compliance:

Billing Audits

• Prospective

• Retrospective

Relationship with FI

• Process for handling errors

• Proper reporting

Training

Disciplinary Consistency

Keys to Compliance:

Billing Audits

• Prospective

• Retrospective

Relationship with FI

• Process for handling errors

• Proper reporting

Training

Disciplinary Consistency

Patient Inducements

Advisory Opinion

Medical related items not permitted

• Pagers

• Beepers

• Child helmets

PPS issue (cherry-picking)

Waiver of Co-payments

Advisory Opinion

Medical related items not permitted

• Pagers

• Beepers

• Child helmets

PPS issue (cherry-picking)

Waiver of Co-payments

Compliance Preparation

Sales Training

Contract Training

Audit performance

• Sales

• Co-payments

• Other waivers

• Collaterals

• Bonus Structures and Performance Criteria

Compliance Preparation

Sales Training

Contract Training

Audit performance

• Sales

• Co-payments

• Other waivers

• Collaterals

• Bonus Structures and Performance Criteria

Corporate Integrity Agreements

Home Care Model

Training

• General

• Contracts

• Cost Reporting

• Billing

Audits

• Billing

Structure after PPS

IRO Engagement

Home Care Model

Training

• General

• Contracts

• Cost Reporting

• Billing

Audits

• Billing

Structure after PPS

IRO Engagement

Compliance Implementation

Successful negotiation

Mirror existing compliance program

Demonstrate adequacy of established safeguards

Involvement of senior management

Building the culture of proactive compliance versus the “mandated & dreaded” compliance model

Compliance Implementation

Successful negotiation

Mirror existing compliance program

Demonstrate adequacy of established safeguards

Involvement of senior management

Building the culture of proactive compliance versus the “mandated & dreaded” compliance model

Credit Balances

Compliance Preparation

Define credit balances clearly

Identify credit balances and eliminate co-mingling

Have a policy you can execute

Repay true credit balances within 30 days of credible evidence

How long is to long to research?

Train, Audit, Enforce

Compliance Preparation

Define credit balances clearly

Identify credit balances and eliminate co-mingling

Have a policy you can execute

Repay true credit balances within 30 days of credible evidence

How long is to long to research?

Train, Audit, Enforce

Self Disclosure

Is it self suicide?

How many forms does this take?

What is a self disclosure?

Is there practical lessons already learned?

Is it self suicide?

How many forms does this take?

What is a self disclosure?

Is there practical lessons already learned?

Compliance Points

Develop key contacts and relationships within the payer community

Close relationship and openness with the FI

Distinguish errors and inappropriate activity

Minimize the need for disclosure at higher levels of the enforcement ladder

• State

• FI

• AG

• OIG

• FBI

Compliance Points

Develop key contacts and relationships within the payer community

Close relationship and openness with the FI

Distinguish errors and inappropriate activity

Minimize the need for disclosure at higher levels of the enforcement ladder

• State

• FI

• AG

• OIG

• FBI

Closing Comments

Chris Anderson

631-844-7390

Chris.Anderson@Gentiva.com

Phil Bradley

404-527-4000

Pbradley@lanlaw.com