Build a Better Corporate Compliance Program

“There are two people here to see you. They said they’re with the Office of Inspector General!”

I get anxious just typing this phrase.

The Office of Inspector General (OIG), Health and Human Services (HHS) has one mission – to protect the integrity of their programs, as well as the health and welfare of program beneficiaries. The HHS OIG has over 1,600 individuals dedicated to combating fraud, waste and abuse, and the OIG is closely monitoring the hospice industry. OIG investigations can result in hefty fines, Medicare program bans, seizure of assets, even prison time. The Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2016 describes numerous hospice infractions uncovered by the OIG and their associated penalties. For example:

A hospice owner was sentenced to 3 years in prison and ordered to pay $1.1 million dollars in restitution for conspiracy to commit health care fraud. The owner admitted to conspiring to bill Medicare and Medicaid for hospice services for patients who were not terminally ill.

A nurse who authorized and supervised the admission of inappropriate and ineligible patients for hospice services was sentenced to over one year in prison, 3 years supervised release, and over $230,000 restitution.

A provider paid $18 million to resolve civil False Claims Act allegations that it admitted and recertified patients for hospice care who were not eligible for such care.

The OIG plans to continue investigative efforts focused on finding and reducing improper payments, and identifying and preventing fraud. In fact, the OIG has stated that future plans will include additional oversight of hospice care. The 2017 OIG Workplan iterates three hospice areas of focus.


Medicare Hospice Benefit Vulnerabilities and Recommendations for Improvement: A Portfolio

The OIG and others have identified vulnerabilities in payment, compliance, and oversight. Additionally, quality-of-care concerns are present. The Workplan aims to summarize OIG evaluations, audits and hospice investigative work, and will highlight key recommendations improvement and protecting those served.


Review of Hospices’ Compliance with Medicare Requirements

OIG will review hospice medical records and billing documentation to determine whether Medicare payments for hospice services were made in accordance with Medicare requirements.


Hospice Home Care – Frequency of Nurse On-Site Visits to Assess Quality of Care and Services

OIG plans to determine whether registered nurses made Medicare CoP required on-site visits to the homes of Medicare beneficiaries who were in hospice care to assess quality of care and services provided by the hospice aide and determine whether the patient’s needs are being met.

It is obvious that intense scrutiny of hospice providers will continue. Hospice agencies should expect close reviews of hospice medical records and billing documentation; perhaps even tougher surveys. Is your hospice agency in compliance with regulations? Are you at risk of fraud and / or abuse due to inadequate business practices? Can you show proof of the actions you took to prevent, identify and report fraud and abuse? Do staff know and adhere to the CoPs?

Act now to identify potential problems and correct known issues with your business practices, corporate compliance plan and staff education. Relias Learning’s Hospice Compliance Series will lead you through the “hows” of corporate compliance – Plan Development, Implementation, Maintenance, and Evaluation –  because no one wants to hear, “There are two people here to see you. They said they’re with the Office of Inspector General!”

Ready to take the next step? Learn more about the compliance solutions we offer hospice agencies.

Lou Ann Robinson

Product Manager Home Health, Hospice, and Palliative Care, Relias

Ms. Robinson is an experienced speaker, educator, process analyst, and quality director, with over 30 years of clinical nursing practice and management experience in home health. Ms. Robinson is recognized for her expertise in process / performance improvement and quality assurance, serving for 10 years as the Director of Quality and Education for a number of home health agencies. Committed to results-oriented business practices, Ms. Robinson’s favorite question is “WHY?”. She believes passionately in community-based disease management, patient self-management, and quality care. Ms. Robinson holds degrees in both nursing and accounting

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