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Fraud and abuse: What does it have to do with me?


Impacts on Your Hospice Documentation is the key Keys for Clinical Staff Thought for the Day Effects of Documentation Effects of Documentation Important ... – PowerPoint PPT presentation

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Title: Fraud and abuse: What does it have to do with me?

Fraud and abuse What does it have to do with
(No Transcript)
  • 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
  • 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

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, Alzheimers,
  • GIP length of stay greater than 5 days or 7 days

Audits for Fraud and Abuse in Hospice
Types of Contractors
  • Contractors reviewing hospice claims (not
  • 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

Legal Oversight
Compliance Oversight
Routine Business
Source Strafford Publishing
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
  • 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
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
Why Should We Care?
Impacts on Your Hospice
  • Claims payment for patient care may stop
  • Could impact staffing, salaries, hospice
  • Patient care practices may be in question
  • Your hospices claims data will be compared to
    others in your state, your MAC region and the
  • Focus areas include
  • Level of care review of GIP
  • Length of stay
  • Certain diagnoses dementia, debility, COPD

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

Keys for Clinical Staff
Thought for the Day
Fast is fine, but accuracy is everything. Wyatt
Effects of Documentation
Descriptive, consistent documentation
Good survey outcomes
Defensible claims
Compliant, reputable, successful hospice that
delivers quality patient care at EOL
Effects of Documentation
Vague, inconsistent, documentation
marginal survey outcomes
More difficult to defend claims
Compliance issues, cash flow issues even if
hospice delivers good patient care
Important Aspects of Hospice Documentation
  • Patients condition
  • Status of the family or caregiver
  • The environment of care
  • Description of care/services provided
  • The patients pain symptom presentation and
    associated interventions and evaluations
  • Communication with the physician and other team
  • The observed or verbal patient/family response(s)
    to interventions and care

Other important aspects of documentation
Documentation should be legible
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

Documentation Accuracy
  • 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
  • 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
  • Documentation should be
  • Objective
  • Concise (more is not always better)
  • Authentic
  • Timely
  • Comprehensive, but pertinent
  • Consistent
  • Tell the patients/familys story

Nurse and Psycho-social Documentation
  • Nurses documentation painted the clinical
    picture of eligibility
  • Psycho-social documentation did not match
  • Example
  • Patient with dementia, the nurses 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
  • Change documentation format to prompt
    psychosocial staff to write their observations
    relating to the patients 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
  • Incorrect Note
  • Patient smiled and greeted chaplain upon arrival
    into patients room.
  • Talked about her husband and family members while
    holding chaplains 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 husbands 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
    patients daughter to offer support for
    anticipatory grief.

Keys for Managers and Leadership
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

Scrutiny You Can Avoid
  • Physician signatures appear on cert and recert
  • 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)

The Physician Narrative
  • Components of a comprehensive and adequate
    physician narrative should include
  • Specifics of the patients condition the most
    important thing
  • Evidence of a decrease in anthropomorphic
  • Recent hospitalizations or ED visits
  • Information about other significant complications
    in addition to the LCD-specific criteria
    appropriate for that particular diagnosis

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

Notice of Election Form
  • Content The election statement must include
    five elements
  • 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

Notice of Election Form (Cont.)
  • 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

Protocols for Audits and Record Review
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
  • Access to medical records
  • Response time for copying

Mail Room
  • Mail/ fax comes into hospice organization
  • Locate sender information
  • Consults state specific auditor list for company
  • If located, staff delivers letter/fax to
    administrator or
  • Company name not located on auditor list staff
    member processes mail/ fax per hospices policy
  • Chain of command

Staff member interviews
  • Auditors may request to interview clinical staff
  • Why?
  • How should staff prepare?
  • What are auditors looking for?

OIG Work Plan and Recent Reports
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.

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.

OIG Report Issued on Part D and Hospice
Summary of Findings
  • 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
  • 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
  • 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

What a hospice should do
  • Complete a comprehensive assessment of the
    patients 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

Developing a Compliance Plan
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
  • Protocol for reviewing processes that may be out
    of compliance with current laws and regulations.

OIG Compliance Guidance
  • Published in 1999
  • Still valid today
  • 28 areas of risk
  • Find complete list at
  • and abuse

Risk areas for hospice fraud and abuse
  • Eligibility
  • Does this patient meet the eligibility
    requirements for admission to the hospice
  • 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
  • Level of care
  • Does the level of care match the patients
    symptom management concerns or family need for
  • 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
  • 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
NEW Regulatory and Compliance Center Buttons
NHPCO members enjoy unlimited access to
Regulatory Assistance Feel free to email
questions to
Regulatory and Compliance Team at NHPCO
  • Jennifer Kennedy, MA, BSN, RN
  • Director, Compliance and Regulatory Affairs
  • Judi Lund Person, MPH
  • Vice President, Compliance and Regulatory
  • Email us at