1 FRAUD AND ABUSE: WHAT DOES IT HAVE TO DO WITH ME? 2 Headlines… 3 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 Hospice Headlines… 4 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. Other Impact on Hospices? 5 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 6 Audits for Fraud and Abuse in Hospice Types of Contractors 7 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) New Levels of Scrutiny 8 DOJ OIG Legal Oversight OVERSIGHT ZPIC/PSC MIC Compliance Oversight FI/Carrier/MAC RAC Routine Business QIO CERT RISK Source: Strafford Publishing Hospice Activity 9 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 ZPIC Contractors 10 ZPIC 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 11 Why Should We Care? Impacts on Your Hospice 12 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 Documentation is the key 13 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 14 Keys for Clinical Staff 14 Thought for the Day 15 Fast is fine, but accuracy is everything. Wyatt Earp Effects of Documentation 16 Descriptive, consistent documentation Good survey outcomes Compliant, reputable, successful hospice that delivers quality patient care at EOL Defensible claims Effects of Documentation 17 Vague, inconsistent, documentation marginal survey outcomes Compliance issues, cash flow issues even if hospice delivers good patient care More difficult to defend claims Important Aspects of Hospice Documentation 18 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 Other important aspects of documentation Documentation should be legible 19 Documentation: Accuracy 20 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 Documentation: Accuracy 21 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 Other Important Aspects of Documentation 22 Documentation should be: Objective Concise (more is not always better) Authentic Timely Comprehensive, but pertinent Consistent Tell the patient’s/family’s story Nurse and Psycho-social Documentation 23 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.” Two-fold strategy to improve compliance 24 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 Examples of Documentation 25 Correct Note: 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. 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. 26 Keys for Managers and Leadership Focus for Staff Leadership 27 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 Scrutiny You Can Avoid 28 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 Form Content – The election statement must include five elements: 1. 2. Identification of the particular hospice that will provide care to the individual 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. 4. 5. Acknowledgement that certain Medicare services, as set forth in paragraph (d) of this section, are waived by the election 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 The signature of the individual or representative Verbal election is not acceptable Cannot be backdated 33 34 Protocols for Audits and Record Review Front desk 35 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 Mail Room 36 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 Staff member interviews 37 Auditors may request to interview clinical staff Why? How should staff prepare? What are auditors looking for? 38 OIG – Work Plan and Recent Reports FY2013 OIG Work Plan 39 Acute-Care Hospital Inpatient Transfers to Inpatient Hospice Care Hospice Marketing Practices and Financial Relationships with Nursing Facilities 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. 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. FY2013 OIG Work Plan 40 Medicaid: Hospice Services: Compliance With Reimbursement Requirements We will determine whether Medicaid payments for hospice services complied with Federal reimbursement requirements. OIG Report Issued on Part D and Hospice Summary of Findings 41 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 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 copays 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 44 Developing a Compliance Plan Compliance plans 45 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. OIG Compliance Guidance 46 Published in 1999 Still valid today 28 areas of risk Find complete list at: www.nhpco.org/regulatory/fraud and abuse Risk areas for hospice fraud and abuse 47 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? Risk areas for hospice fraud and abuse 48 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? Contacts for Reporting Fraud 49 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). NEW Regulatory and Compliance Center 50 www.nhpco.org/regulatory NEW Regulatory and Compliance Center Buttons 51 52 Q&A NHPCO members enjoy unlimited access to Regulatory Assistance Feel free to email questions to regulatory@nhpco.org 52 Regulatory and Compliance Team at NHPCO 53 Jennifer Kennedy, MA, BSN, RN Director, Compliance and Regulatory Affairs Judi Lund Person, MPH Vice President, Compliance and Regulatory Leadership Email us at: regulatory@nhpco.org