Compliance Program Development and Assessment

Regulatory compliance is taking on more importance and urgency in the hospice industry. According to recently published reports it is reasonable to assume that whatever “benefit of the doubt” that federal and state regulators have shown towards hospices in the past, those times are over. Indeed, there may even be a “perfect storm” of regulatory oversight brewing as the Office of the Inspector General (OIG), The Centers for Medicare and Medicaid Services (CMS) and the Medicare Payment Advisory Commission (MedPAC) all focus more intently on the provision of hospice services with the goal of reducing, if not eliminating, the (gratefully) small number of hospices in the country that knowingly abuse the various federal, state and private hospice payment policies and benefits and indeed beneficiaries themselves.

Unfortunately, the process of weeding out “bad actors” is not an exact science. Many good, law abiding hospices that are providing excellent care to their patients and families can unwittingly become ensnared in these enforcement efforts and suffer dire consequences. The best way of preventing systemic violations of the rules and regulations governing the provision of hospice care is to establish a comprehensive corporate compliance plan and program that effectively and efficiently limits the opportunity for bad behavior and reinforces the ethical values of most hospices.

Summit Business Group, LLC has a long history of assisting hospices in their approach to regulatory compliance, led by it founder, Jay Mahoney. As noted elsewhere on this site Jay was intimately involved in the development of the Medicare/Medicaid Hospice Benefit. Since that time he has completed the Harvard School of Public Health program on operationalizing a corporate compliance program, and he has presented on the topic of corporate compliance at dozens of national and state conferences. Jay has also written extensively on hospice corporate compliance issues, and has been featured in several national publications on the topic. Jay was one of the contributors to NHPCO’s Compliance Program Toolkit, and was one of the authors of the HIPAA Privacy Rule: Compliance Resources for Hospices. Of all the awards and honors that Jay has received over the years, the one that may be of most relevance to regulatory compliance is the DHHS’s Office of the Inspector General’s Integrity Award. Additionally, Summit established and continues to manage the Hospice Compliance Network.

The Compliance Plan and Program

Corporate compliance programs are voluntary for hospice programs. Nevertheless, the Office of the Inspector General (OIG) has been very consistent in their encouragement of establishing effective compliance programs and conducting routine assessments of that effectiveness. Although such programs do require a substantial commitment of organizational resources, including the executive management’s time, the creation of effective compliance programs has proven to be a cost effective tool in limiting regulatory related problems for hospices. Additionally, the organizational formality of compliance programs can be scalable to the size and complexity of the hospice program.

Establishing a Compliance Program

Summit can assist in the development of compliance programs, including:

• Structure of the program
• Development of the compliance plan
• Creation of compliance policies and procedures
• Compliance training for management positions
• Baseline reviews of the compliance functions of a hospice, including:
  
  
  1. Compliance with the OIG’s identified risk areas,
  2. MHB Conditions of Participations,
  3. Compliance with the HIPAA Privacy and Security Rules,
  4. Evaluation of selected medical records for compliance with such issues as eligibility; discharges and revocations; appropriate and timely signatures; development, execution and monitoring of plans of care; medical records relationship to and support of claims. Special attention will be placed on records of patients with lengths of stay greater than 180 days,
  5. Review of billing procedures related to compliance with applicable regulations and violations of the False Claims Act,
  6. Review of Review marketing materials for issues associated with informed consent and civil rights,
  7. Review contracts with a focus on potential violations of kick back statutes. Summit does not provide legal advice; however, these reviews are provided by attorneys who will identify problem areas for which for which the hospice may wish to seek specific legal advice,
  8. Review of internal reporting mechanism(s), investigations and resolutions of any internal investigations,
  9. Review of any external investigations and the resolution of any issues associated with those investigations,
  10. Review of hiring practices associated with the compliance function, including policies and procedures related to determining that potential employees (and referring physicians) have not been excluded from federal programs, including Medicare,
  11. Review of disciplinary policies and procedures associated with compliance related issues.
  12. Evaluation of the program’s effectiveness through review of such issues as staff education and training, etc.
  
  
• Summit is in the process of piloting a new compliance service provided by one of our physician reviewer associates that focuses on documentation and the new Conditions of Participation addressing the role of the physician and hospice Medical Director in conducting assessments of potential patients, determining eligibility and admissions and the development of plans of care. This service includes:
  
  
  1. Desktop review of sample medical records,
  2. Report on the findings of this review,
  3. On site training for physicians and staff