Hospital compliance bad bet for home care

As a hospital-based agency director, you may be called on to develop your own compliance plan, or you may fall under the hospital’s compliance program. But in either case, you must remember that hospital compliance and home care compliance have different issues.

The hospital may already have a plan in place, says health care attorney John C. Gilliland II of Crestview Hills, KY, "to varying degrees . If the hospital-based agency is a department of the hospital, its compliance effort will be part of the hospital’s compliance program."

But an agency with its own provider number and its own board of directors, has "more to do," says Gilliland, who helps home care providers develop plans and conducts seminars around the country on compliance. "The biggest thing I’ve observed with hospital-based agencies is that hospitals don’t understand home care, either the business or health care laws. The hospital based agency will have some unique issues to address in its compliance plan," he says.

For instance, says Gilliland, "There is the knowledge in the industry that in home care you have falsified visits. Hospitals don’t run into that." Another problem peculiar to home care, the attorney says, is in billing. "Communication is poor; it’s dependent on nurses to document time. Misunderstandings between clinical and billing is a high area of risk in home care. It’s different in hospitals. Home care reimbursement issues, as well as issues of homebound status or medical status are different than hospitals."

As with any compliance plan, it begins with a commitment from the entity’s board of directors. That means publishing a statement by the board of its commitment to compliance and a code of ethics, Gilliland says.

"For an agency that’s a department of a hospital," he explains, "the hospital board will be doing that. The individual director of home care won’t play a big role. But if the agency is separate, the home care board will do those things."

Lorraine Waters BSN, C, MA, the director of Southern Home Care, a hospital-based agency in Jeffersonville, IN, has begun the process of writing a compliance plan for her agency. But she will rely on the hospital vice president of finance for overall program development. Her agency’s compliance plan will become part of the hospital’s program.

"I just gathered some information they needed," she says. "We are looking at what our current practices are, looking a what we have in place. Then our attorney will look at it. It’s tedious. As a director, you have to step outside your role and look at things with an objective eye."

Waters too is aware of the differences in hospital compliance and compliance in home care and the potential problems that poses. "Billing falls under the hospital’s billing practices," she says, "and quality management has people who don’t know about home care and probably don’t think about fraud and abuse either."

Billing, of course, is a primary area targeted by the federal fraud and abuse audits. Waters will monitor the development of her agency’s plan and make recommendations when necessary, she explains.

In any event, Gilliland points out, there is no "off-the-shelf compliance plan" that will fit all home care agencies or even all hospital-based agencies. That’s why it’s important to consult your agency attorneys or your hospital’s legal department. "In fact," says Gilliland, "you need accounting, legal, and clinical advice, depending on the in-house expertise.

"For a hospital-based agency, the home health cost report is complex. Some accountants specialize in Medicare cost reports. If your cost reports have not been done by a home care cost accountant, then as part of your compliance plan development, you should have at least three cost reports viewed by an accountant. With hospitals, it is reviewed by the hospital accountant or hospital attorneys who are not familiar with home care."

Although Gilliland advises using outside accountants and lawyers well versed in home care, he stresses that the hospital’s attorneys and CPAs should be included. "The home care cost accountant doesn’t have to replace anybody," he says. "They can work with the hospital’s CPAs like I work with the hospital’s attorney." n