Conduct a self-audit of hospice program to identify risk areas

Expert offers guide to effective compliance

It's been more than six years since the Office of Inspector General (OIG) published its compliance program guidance for hospices, listing 28 areas in which hospices are particularly vulnerable to fraud and abuse.

Still, many hospice directors and staff are unfamiliar with these areas and could use some assistance in developing effective corporate compliance programs, an expert notes.

"In my experience, hospices that have an effective compliance program tend to be stronger hospices," says Heather P. Wilson, PhD, president of Weatherbee Resources Inc., a company that provides compliance consulting and other services, of Yarmouth Port, MA. Wilson is the co-chair of the regulatory subcommittee at the National Hospice and Palliative Care Organization (NHPCO) of Alexandria, VA, and the leader of the education work group at NHPCO.

"When we get a call from a hospice program that's in trouble we ask if they have a compliance program, and if they don't we help them set up one because it protects them in so many ways," Wilson says. "If the government sees they have a viable corporate compliance program it can help mitigate some of the penalties that might otherwise accrue for what has happened."

Wilson was the primary author of the corporate compliance program toolkit published by NHPCO in 2000. The toolkit includes information about conducting audits and monitoring a hospice program to make certain it's in compliance with the regulations, Wilson says.

While many of the risk areas are similar to those for home health agencies, others are hospice-specific, Wilson says.

"Some of the risk areas are related to marketing, and others are related to billing, and a number of them are related to the provision of hospice care in nursing homes," Wilson says. "The remainder are specifically focused on the Medicare Conditions of Participation [COPs]."

Wilson provides this short guide to what hospices can do to reduce compliance risk:

1. Set the scope of an auditing/monitoring program.

Hospices should determine which areas will be monitored on an ongoing basis and determine the frequency of audits and who will conduct the audit, Wilson says.

"Who has the best level of competency in terms of what needs to be looked at?" Wilson says. "Most hospices will have to do it internally, so who are going to be the best people to do it?"

The audit protocol might focus on these areas:

  • Trouble areas for the hospice;
  • OIG's corporate risk areas;
  • Substandard care areas;
  • Compliance with Medicare COP;
  • Patient admission.

"The most significant risk area is the one of admitting patients to hospice who are not terminally ill," Wilson says.

"Many hospices call us because they've had claim denials or are under focused medical review by a fiscal intermediary," Wilson explains. "It comes down to continued eligibility for the person with hospice care and the eligibility for the level of care that they're billed for."

Another risk area is when hospices bill for a higher level of care than is necessary, Wilson says.

"If you don't have documentation in your records, you could be at risk for billing for a higher level of care than is necessary," she says.

2. Include standard compliance components.

"In setting up an auditing and monitoring protocol for a corporate compliance program, audit for risk areas, but also audit for effectiveness of the compliance program," Wilson suggests.

The standard components of a compliance program are the standards of conduct, she says.

"What standards of conduct emphasize is an organization's commitment to conduct business in an ethical manner," Wilson says. "We recommend they adopt NHPCO's code of ethics because these are essentially the same thing."

It's not enough for a hospice to say that it has accepted NHPCO's code of conduct, however, she says.

"The code of conduct should be visible and posted in a prominent location with staff training material," Wilson says.

3. Customize a compliance manual.

Also, it's not helpful to purchase a compliance manual or toolkit and then let it gather dust on a bookshelf, Wilson says.

"I've actually seen it in my consulting work where a program purchased our manual and just photocopies the policies and procedures and doesn't customize them to their own organization," Wilson says. "So that doesn't work—the manuals are intended to be helpful, but not the actual program."

A staff person should be designated to work on the tool kit or compliance manual, and, ideally, a compliance officer and compliance committee should be established, Wilson says.

While it's okay to use NHPCO's code of ethics, which is strong and touch on all aspects of hospice ethics, it's equally important to read them and internalize them, making them an organization's own code, Wilson explains.

4. Develop policies and procedures.

"In the toolkit we provide sample policies and procedures that are needed," Wilson says.

"You need to look at policies and procedures for each of the components of a corporate compliance program and for each of the risk areas," she says. "Also, address each risk area in terms of how you deal with those risk areas."

The risk areas are the 28 listed by the OIG. (See table of OIG hospice risk areas.)

The toolkit provides samples of policies and procedures and suggestions about different components to be included, Wilson notes.

5. Find the ideal person to be a compliance officer.

"Basically, it happens in hospice all the time that you go into work one morning and your job description has changed," Wilson says. "All of a sudden you're the HIPAA officer or the compliance officer."

While big hospice chains can afford to have a specific position designated to the role of compliance officer, smaller hospice programs have to find an employee who can fill that role while performing other tasks, as well, Wilson says.

"The point of it is to have a focal point of accountability for the compliance program, and it should be someone who has the authority in the organization and who is well-regarded," Wilson says.

The person could be a clinical manager, clinical director, nurse manager, of have some other position, she adds.

"It really is a matter of looking at your organization and deciding who is the most appropriate person to take on that responsibility," Wilson says.

6. Educate staff effectively.

"You can't have an effective compliance program if the staff don't know it exists," Wilson says.

"The training should be an initial training when the compliance program is rolled out and an annual inservice, as well as being included in new staff orientation," Wilson says.

Part of the training, which might take 45 minutes to an hour, should include an introduction to the compliance officer and information that is included in the employee handbook about compliance, she adds.

7. Establish a reporting mechanism.

The staff should know that there is a reporting mechanism in which they can report compliance concerns, Wilson says.

"This can help deal with whistleblower issues," Wilson says.

For example, if a hospice has a disgruntled employee who brings a lawsuit against the hospice program, then some of the damage could be mitigated by the hospice having a reporting mechanism, Wilson says.

The mechanism should give staff a way to call about potential fraud or abuse without fearing retaliation, and they should be adequately trained on how to use it, she says.

It could be a toll-free number for fraud and abuse that is established by an outside contractor, she says.

"It doesn't have to be a hotline number," Wilson says. "You could do a suggestion box or provide the contact information of the compliance officer, as well."

8. Establish consequences and corrective actions.

When problems or noncompliance issues are discovered, there should be a protocol for disciplinary action, Wilson says.

"What you need is a policy and procedure that says a hospice employee would be disciplined for noncompliance with regulations or violating the organization's standards of conduct, code of ethics," Wilson says. "Let people know these violations are serious and there are consequences for not adhering to the compliance program."

When an audit finds problems within the hospice, it's important to demonstrate that the management will do everything necessary to correct it, Wilson says.

"If a hospice receives an overpayment, it should immediately pay it back," she says.

Also, if a compliance problem is discovered the hospice should consider retaining an attorney to assist in any governmental communication, Wilson suggests.

"What I find is that hospices are so scrupulous and so intense on doing the right things that they over-do it," she says. "They just need to be protective of themselves and their organization, so when they find something wrong their legal counsel can help them with disclosing it."

Most of the fraud and abuse problems committed by hospices are due to a lack of understanding or knowledge of regulations, Wilson adds.

Or, as it says in the planning guide, "Challenges abound, but perhaps the most threatening of these challenges is complacency."

Too often in smaller communities, there is no single voice for hospitals and they end up being left out of the local emergency planning committee. Wise advises hospitals to set aside their competitive nature and ensure they have a role in communitywide planning.

The Joint Commission developed the guide in partnership with the Illinois Department of Public Health, the Maryland Institute of Emergency Medical Services Systems, and the National Center for Emergency Preparedness at Columbia University. It also convened two expert roundtable meetings in 2004.

Wise notes these lessons learned from past disasters:

  • Hospitals must be able to stand alone for at least 48 to 72 hours.
  • Hospitals must take care of the personal needs of their staff.
  • Maintaining a communications system is crucial.

Even if you make it on your own, you need contact with the outside world. Hospitals need an emergency communications system, says Wise.

For example, after Sept. 11, New York hospitals developed an 800 MHz phone system that would connect hospitals and the Emergency Operations Center. The closed-circuit system would not be affected by overloading on the public circuit. The phone system worked well during the Northeast blackout in 2003.

Need More Information?

  • Heather P. Wilson, PhD, President, Weatherbee Resources Inc., 161 Main St., Yarmouth Port, MA 02675. Telephone: (508) 375-0098. Email: