FRAUD AND ABUSE:

WHAT DOES IT HAVE TO DO WITH ME?

1

2

Headlines…

Fraud accounts for 19 percent of the $600 billion to $800 billion in waste in the U.S. healthcare system annually.

Investigators recovered a record-breaking $4.1 billion in health care fraud money during 2011

OIG reports $3.0 billion in fraud and abuse recoveries in 2010 Semi-annual Report to Congress

3

Hospice Headlines…

False Claims Act: July 2012: Altus Healthcare and Hospice, Atlanta, GA:

$555,572 settlement. Falsely submitted claims for inpatient hospice services.

March 2012: Five nurses, Philadelphia hospice, indicted for conspiring to defraud Medicare of millions of dollars. “allegedly authorized and supervised the admission of

inappropriate and ineligible patients for hospice services, resulting in approximately $9.32 million in fraudulent claims“

The creation of false documents related to services for about 150 patients

Nursing supervisor penalty: Could be sentenced to 108 to 135 months in prison, a fine of up to $150,000, and a $1,400 special assessment.

Other nurses: Possible prison terms ranging from 21 to 33 months, and fines from $50,000 to $60,000.

4

Other Impact on Hospices?

More scrutiny Identification of aberrant behavior

among hospice providers – comparing providers in state, MAC, CMS region

Targets Long and very long stays Particular diagnoses – debility, Alzheimer’s,

AFTT, COPD GIP length of stay greater than 5 days or 7

days

5

Audits for Fraud and Abuse in Hospice

6

Types of Contractors

Contractors reviewing hospice claims: (not all-inclusive) MAC – ADR process Recovery Audit Contractors (RAC) Medicaid Integrity Contractors (MIC) Medicaid Recovery Audit Contractors Zone Program Integrity Contractors (ZPIC) Office of Inspector General (OIG) Department of Justice (DOJ)

7

New Levels of Scrutiny

CERT

QIO Routine Business

FI/Carrier/MAC

MIC

RAC

ZPIC/PSC

OIG

DOJ

Compliance Oversight

Legal Oversight

RISK Source: Strafford Publishing

8

Hospice Activity

RAC Not hospice specific

but connected to hospice DME claims when patient

is hospice patient Part B billing when

patient is hospice patient Condition Code 07 when

patient is hospice patient – inpatient and outpatient

Hospice related services – inpatient and outpatient

Required to have CMS approval before commencing

MIC Audits several states

ZPIC Active in 38 states Whistleblower cases Data mining/On-site

visits No CMS approval

required Extrapolation possible

-- % of claims applied to universe of claims

9

ZPIC ContractorsZPIC Zone States

Safeguard Services (SGS)

1 California & Nevada

AdvanceMed 2 Washington, Oregon, Idaho, Utah, Arizona, Wyoming, Montana, North Dakota, South Dakota, Nebraska, Kansas, Iowa, Missouri, Alaska

Cahaba Safeguard Services

3 Minnesota, Wisconsin, Illinois, Indiana, Michigan, Ohio, Kentucky

Health Integrity 4 Colorado, New Mexico, Texas and Oklahoma

AdvanceMed 5 Arkansas, Louisiana, Mississippi, Tennessee, Alabama, Georgia, South Carolina, Virginia, West Virginia

Under Protest 6 Pennsylvania, New York, Delaware, Maryland, D.C., New Jersey, Massachusetts, New Hampshire, Vermont, Maine, Rhode Island, Connecticut

Safeguard Services (SGS)

7 Florida

10

Why Should We Care?11

Impacts on Your Hospice

Claims payment for patient care may stop Could impact staffing, salaries, hospice

operations Patient care practices may be in question Your hospice’s claims data will be compared to

others in your state, your MAC region and the country

Focus areas include: Level of care – review of GIP Length of stay Certain diagnoses – dementia, debility, COPD

12

Documentation is the key

Clinical staff documentation Preparation of bills

Pre submission review Checklist for signatures, dates, completion

New regulatory requirements in place? Brief physician narrative Face-to-face encounter Compliance plan

13

Keys for Clinical Staff

14

14

Thought for the Day

Fast is fine, but accuracy is everything.

Wyatt Earp

15

Effects of Documentation

Descriptive, consistent

documentation

Descriptive, consistent

documentation

Good survey

outcomes

Good survey

outcomes

Defensible claims

Defensible claims

Compliant, reputable, successful

hospice that delivers quality patient care at

EOL

16

Effects of Documentation

Vague, inconsistent, documentatio

n

marginal survey

outcomes

More difficult to

defend claims

Compliance issues, cash flow

issues even if hospice delivers

good patient care

Compliance issues, cash flow

issues even if hospice delivers

good patient care

17

Important Aspects of Hospice Documentation Patient’s condition Status of the family or caregiver The environment of care Description of care/services provided The patient’s pain & symptom

presentation and associated interventions and evaluations

Communication with the physician and other team members

The observed or verbal patient/family response(s) to interventions and care

18

Other important aspects of documentation

Documentation

should be legible

19

Documentation: Accuracy

Rectal exam revealed a normal size thyroid She stated that she had been constipated for most of

her life until 1989 when she got a divorce I saw your patient today, who is still under our car for

physical therapy She is numb from her toes down The patient suffers from occasional, constant,

infrequent headaches Patient was alert and unresponsive When she fainted, her eyes rolled around the room Patient has chest pain if she lies on her left side for

over a year

20

On the second day the knee was better and on the third day it had completely disappeared

The patient is tearful and crying constantly. She also appears to be depressed

Discharge status: Alive but without permission The patient refused an autopsy The patient expired on the floor uneventfully Patient has left his white blood cells at another

hospital The patient's past medical history has been

remarkably insignificant, with only a forty-pound weight gain in the past three days

Documentation: Accuracy 21

Other Important Aspects of Documentation

Documentation should be: Objective Concise (more is not always better) Authentic Timely Comprehensive, but pertinent Consistent Tell the patient’s/family’s story

22

Nurse and Psycho-social Documentation Nurses’ documentation painted the clinical

picture of eligibility Psycho-social documentation did not match

Example: Patient with dementia, the nurse’s note

indicated a FAST score of 7d while the social worker documented that the “patient was in the activity room putting together a puzzle upon arrival.”

23

Two-fold strategy to improve compliance Change documentation format to prompt

psychosocial staff to write their observations relating to the patient’s hospice eligibility within the scope of their practice

The second was to provide education on the signs and symptoms of physical decline related to specific disease types which they should look for

24

Examples of Documentation

Incorrect Note: Patient smiled and greeted

chaplain upon arrival into patient’s room.

Talked about her husband and family members while holding chaplain’s hand.

Chaplain provided a ministry of presence, prayed with patient, and provided a follow-up phone call to the daughter.

Patient denied pain and appeared comfortable.

Correct Note: Data: Patient was received in her

wheelchair, leaning to her left side with support pillows as aide was completing feeding her lunch. Patient was coughing after eating and stared into space. Care plans being addressed: altered mental status; spiritual presence needs.

Action: Chaplain greeted patient, held her hand, encouraged eye contact, read scriptures and prayed with patient.

Results: When chaplain brought up husband’s name, patient began to talk about him as if he were still alive, although he has been deceased for years. Patient appeared comforted by prayers and scripture reading as evidenced by calm affect and closed eyes.

Observations: Patient coughed after mealtime, leaned to side, and was unable to engage in reality-based conversation.

Plan: Chaplain will visit patient in two weeks to provide spiritual presence and will phone patient’s daughter to offer support for anticipatory grief.

25

Keys for Managers and Leadership

26

Focus for Staff Leadership

Know the regulations Develop AND follow protocols to give

maximum time to respond to ADRs and medical record requests

Hire excellent clinicians Review documentation regularly

Completeness Accuracy Objectivity

27

Scrutiny You Can Avoid28

Physician signatures appear on cert and recert forms

Dates filled in with physician signatures Notice of Election has required components Certification and recertification forms meet

regulatory requirements All components of certification present

Attestation when face-to-face encounter conducted

Physician narrative written and signed

The Physician Narrative

Components of a comprehensive and adequate physician narrative should include: Explanation of the clinical findings that

supports a life expectancy of 6 months or less Reference to specific LCDs as appropriate Reference to prognostic indicators or symptom

management scales as appropriate Reference to functional status using recognized

tools (PPS, ECOG, Karnofsky, FAST, NYHA)

29

The Physician Narrative

Components of a comprehensive and adequate physician narrative should include: Specifics of the patient’s condition – the

most important thing Evidence of a decrease in

anthropomorphic measurements Recent hospitalizations or ED visits Information about other significant

complications in addition to the LCD-specific criteria appropriate for that particular diagnosis

30

Certification: Form Content Six months or less prognosis statement –

if the terminal illness runs its normal course

Benefit period dates to which the certification or recertification applies

Signature and date by the physician(s) – no stamps

Physician narrative Physician narrative attestation Face-to-face encounter date Face-to-face encounter attestation

31

Notice of Election FormContent – The election statement must include five elements: 1. Identification of the particular hospice

that will provide care to the individual2. The individual's or representative's

acknowledgement that he or she has been given a full understanding of the palliative rather than curative nature of hospice care, as it relates to the individual's terminal illness

32

Notice of Election Form (Cont.)

3. Acknowledgement that certain Medicare services, as set forth in paragraph (d) of this section, are waived by the election

4. The effective date of the election, which may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement

5. The signature of the individual or representative

Verbal election is not acceptable Cannot be backdated

33

Protocols for Audits and Record Review

34

Front desk

If an auditor arrives in person? Ask for identification Is the company listed on the state specific list of

auditors? Chain of command

Plan in place Do you know who they are? Want a conference room? Away from patient

care teams… Access to medical records Response time for copying

35

Mail Room

Mail/ fax comes into hospice organization Locate sender information Consults state specific auditor list for

company name If located, staff delivers letter/fax to

administrator or Company name not located on auditor list

– staff member processes mail/ fax per hospice’s policy

Chain of command

36

Staff member interviews

Auditors may request to interview clinical staff

Why? How should staff prepare? What are auditors looking for?

37

OIG – Work Plan and Recent Reports

38

FY2013 OIG Work Plan

Acute-Care Hospital Inpatient Transfers to Inpatient Hospice Care Review Medicare claims for inpatient stays when

beneficiary was transferred to hospice care and examine the relationship between the acute-care hospital and the hospice provider.

Hospice Marketing Practices and Financial Relationships with Nursing Facilities Review hospices’ marketing materials and practices

and their financial relationships with nursing facilities. Medicare Hospice General Inpatient Care

Use of GIP from 2005 to 2010. Assess appropriateness of GIP claims and beneficiary drug claims billed under Part D.

39

FY2013 OIG Work Plan

Medicaid: Hospice Services: Compliance With Reimbursement Requirements We will determine whether Medicaid

payments for hospice services complied with Federal reimbursement requirements.

40

OIG Report Issued on Part D and Hospice

Calendar year 2009 Prescription analgesic, anti-

nausea, laxative, and anti-anxiety drugs

Prescription drugs used to treat COPD and ALS

Covered under the hospice per diem.

Medicare program could be paying twice for prescription drugs for hospice beneficiaries: once under the Medicare Part A hospice per diem payments and again under Medicare Part D.

Hospice beneficiaries could also be unnecessarily paying copayments for prescription drugs under Part D.

198,543 hospice beneficiaries 677,022 prescription drugs

through Medicare Part D Part D paid pharmacies

$33,638,137 for these prescription drugs

Beneficiaries paid $3,835,557 in copayments

Published July 3, 2012

A-06-10-00059

Summary of Findings41

What this report means for hospices

42

Part D pharmacies may be billing hospices for drugs that could/should be related

Other auditors may also be reviewing “related” prescription drugs

There may be requests for payment for the co-pays paid by the beneficiary

42

What a hospice should do

43

Complete a comprehensive assessment of the patient’s medications

Clearly document in the clinical record which medications will be covered under hospice

Pay for the drugs related to the terminal illness, i.e. inhaler for COPD

Discuss which medications will not be covered by the hospice and why with the patient/ family

Complete an assessment of patients residing in a nursing facility to ensure that pharmacy providers are not billing hospice related medications to another payer once a patient has elected to receive hospice

43

Developing a Compliance Plan

44

Compliance plans

Vigilance is required about compliance activities Compliance with:

Medicare Hospice Conditions of Participation Other hospice regulations Claims submission requirements Eligibility requirements Requirements for continued eligibility

Compliance plan should include: Specific timeframes for internal audits of agency

practices Protocol for reviewing processes that may be out

of compliance with current laws and regulations.

45

OIG Compliance Guidance

Published in 1999 Still valid today 28 areas of risk Find complete list at:

www.nhpco.org/regulatory/fraud and abuse

46

Risk areas for hospice fraud and abuse

Eligibility Does this patient meet the eligibility

requirements for admission to the hospice program?

Does the documentation support eligibility? Site of care

Do the patients in nursing facilities meet the eligibility requirements for hospice?

Is the length of stay appropriate, or were those patients admitted “too early” for hospice care?

47

Risk areas for hospice fraud and abuse Level of care

Does the level of care match the patient’s symptom management concerns or family need for respite?

Is General Inpatient care appropriate and documented in the medical record?

Is GIP evaluated every day? Claims submission

Are the dates of service, Q-codes for location of care, and levels of care accurate?

Do forms have necessary signatures and dates?

48

Contacts for Reporting Fraud Beneficiaries:

Call 1-800-MEDICARE or DHHS OIG hotline at 1-800-HHS-TIPS

(1-800-447-8477)

Providers: Call the DHHS Office of Inspector

General hotline at 1-800-HHS-TIPS (1-800-447-8477).

49

NEW Regulatory and Compliance Center

www.nhpco.org/regulatory

50

NEW Regulatory and Compliance Center Buttons

51

Q&A

52

NHPCO members enjoy unlimited access to Regulatory Assistance

Feel free to email questions to regulatory@nhpco.org

52

Regulatory and Compliance Team at NHPCO

Jennifer Kennedy, MA, BSN, RNDirector, Compliance and Regulatory

Affairs

Judi Lund Person, MPHVice President, Compliance and

Regulatory Leadership

Email us at: regulatory@nhpco.org

53