Simione™ Healthcare Consultants

Back

Give Your Agency a Gift: Set Compliance Goals for 2016


During the holiday season, many of us reflect on the passing year and assess whether we met our desired accomplishments -- for health, happiness or a sense of peace in our lives or families. Likewise, in business, we ask ourselves the same. Did we achieve our patient care goals? Did we mitigate financial risk? Have we cultivated a culture of ethics and compliance in our agency?

Now is the time to set compliance goals for the New Year. Whether you will be assessing your current ethics and compliance program or developing a program from scratch, start fresh and resolve to set new goals. Simione Healthcare Consultants is available to help you set a course.

The healthcare compliance climate continues to heat up with more than $3 billion expected in government recoupments in 2015. In November 2015, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) published the Work Plan Fiscal Year 2016. This Plansummarizes areas of OIG focus by provider type. The OIG will spend extraordinary resources in auditing and investigating Medicare/Medicaid certified providers for past and new or revised initiatives.

Specifically, in home health, the OIG will continue to review compliance with various aspects of the home health prospective payment system (PSS), including documentation required to support the claims paid by Medicare in accordance with federal laws and regulations.

In hospice, the OIG will review the use of the general inpatient care (GIP) level of the Medicare hospice benefit, assessing the appropriateness of hospices’ general inpatient care claims and the content of election statements for hospice beneficiaries who receive GIP care. They will review hospice records for medically necessary services and review beneficiaries’ plans of care for mandated requirements. 

Although a formal Compliance Program is not mandatory under most state laws, it is statutorily required for all certified providers under the Patient Protection and Affordable Care Act (ACA) of 2010.  While HHS has not yet issued regulations applicable to the requirements for Certified Provider Compliance Programs for home health or hospice, agencies are expected to have a viable and evolving compliance program to monitor risk for fraud and abuse. The OIG has demonstrated this expectation by issuing voluntary compliance guidance, as well as consistently citing the seven elements of a compliance program in Corporate Integrity Agreements (CIAs).

A Compliance Program should include the following seven activities as per OIG guidance for home health and hospice organizations:

  1. Implement written compliance program, code of conduct and high-risk policies and procedures
  2. Designate a compliance officer and committee
  3. Provide effective training and education
  4. Establish effective lines of communications
  5. Enforce standards through well-publicized disciplinary measures
  6. Conduct effective auditing and monitoring activities for high-risk areas of business
  7. Respond promptly to allegations of non-compliance or wrongdoing

In each monthly Simione newsletter of 2016, we will provide compliance tips corresponding to elements of a compliance program.  In January, we will start with element number one. After all elements are covered, Simione will provide additional compliance tips pursuant to new mandates or executed Home Health and Hospice CIAs.  See www.oig.hhs.gov for compliance resources and evolving news from the OIG.