New OIG 'Fraud Alert' cites kickback dangers
New OIG 'Fraud Alert' cites kickback dangers
A "Special Fraud Alert" about arrangements between nursing homes and hospices was issued March 25 by the federal Office of Inspector General (OIG). Building on previous OIG reports about the complex relationship between the hospice and nursing home industries (see Hospice Management Advisor, December 1997, pp. 138-139), the report identifies a number of specific practices that could be "suspected kickbacks."
However, this fraud alert "could have been a heck of a lot worse, given the source," says David A. Simpson, MA, LSW, chairperson of the National Hospice Organization (NHO) and executive director of Hospice of the Western Reserve in Cleveland.
A memo faxed to NHO members by NHO president Karen A. Davie explains that the new alert is based on a previous OIG report, "Hospice and Nursing Home Contractual Relations," issued last fall. In that report, OIG recommended that the Health Care Financing Administration (HCFA) work with hospice organizations to educate the hospice and nursing home industries about how to avoid potentially fraudulent inducements for referrals. HCFA concurred with the recommendation, and requested that OIG prepare a document outlining potential anti-kickback violations. The new fraud alert is OIG's answer to that request.
The report can be used by hospices to educate nursing homes that demand more than the law allows for room-and-board payments in their contracts with hospices, Simpson says. He tells the story of how a local nursing home once asked his hospice to pay 125% of its usual reimbursement rate in order to secure a large contract, saying, "other hospices are doing it." Simpson refused.
The new alert reviews "vulnerabilities" identified by OIG in the dual reimbursement mechanism for terminally ill Medicaid nursing home residents who elect the hospice benefit, such as the hospice paying more to the nursing home in room-and-board payments than the facility otherwise would have received if there was no hospice benefit election.
Other specific practices targeted in the fraud alert as "suspected kickbacks" include:
· a hospice offering free goods or goods at below fair market value to induce a nursing home to refer patients to the hospice;
· a hospice paying the nursing home for "additional" services that Medicaid considers to be included in the room-and-board payment;
· a hospice referring its patients to a nursing home in order to induce the nursing home to refer its patients to the hospice;
· a hospice providing free (or below fair market value) care to nursing home patients on the Medicare skilled nursing benefit, with the expectation that the patient will be referred to that hospice after the skilled nursing benefit is exhausted;
· a hospice providing staff at its expense to the nursing home to perform duties that otherwise would be performed by the nursing home.
The Maine legislature has decisively defeated a bill to legalize physician-assisted suicide in that state. Kandyce Powell, RN, MSN, executive director of the Maine Hospice Council (MHC), attributes this vote to the "thoughtful, substantive presentations" by opponents, including hospice representatives, during a six-hour public hearing.
"The legislators heard everything that was said. They knew that the measure had popular support, but that was only part of the story. They also knew this was dangerous social policy," Powell says. However, assisted suicide proponents have vowed to bring the bill back next year, as well as to seek signatures for a citizen referendum on the 1999 ballot.
MHC had scheduled a banquet presentation on pain management issues for legislators in January (see Hospice Management Advisor, February 1998, p. 27). Although various forces - including last minute scheduling conflicts, an electrical power-interrupting ice storm, and another terrific blizzard on the night of banquet - conspired to hold down attendance, a number of legislators and Augusta-area physicians managed to turn out for a powerful presentation by James Cleary, MD, of the University of Wisconsin-Madison, Powell says.
Meanwhile, the hospice council is not waiting passively for future assisted suicide proposals. The council is planning a survey of public attitudes and looking for ways to reach the half of the state's population that doesn't know about hospice. It also appears that the state Department of Human Services will be adding a hospice benefit to Medicaid coverage in the state, effective this summer. Questions as to why Maine did not cover hospice care were raised by legislators during the assisted suicide debate. Human Services spokes person Francis Finnegan explains that the idea simply fell through the cracks.
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Maine is also hosting this year's national meeting of state cancer pain initiatives. The meeting, "Building a Pain Community," will be held June 11-13 at the Radisson East Hotel in Portland. June Dahl, PhD, founder of the first state cancer pain initiative, in Wisconsin, and professor of pharmacology at the University of Wisconsin-Madison, tells Hospice Management Advisor that she hopes hospices will be well-represented at this conference. It will include important discussions about community-building around pain and end-of-life issues.
"A lot of issues that are terribly relevant to hospices, including head and neck cancer pain, pediatric pain, and new pharmacologic approaches to pain, as well as an update on physician-assisted suicide efforts across the country, will be highlighted at the meeting," Dahl says. For more information on this meeting, call the Resource Center for State Cancer Pain Initiatives at (608) 265-4013.
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The American Academy of Hospice and Palliative Medicine recently closed its Gainesville, FL, office. Former executive director Dale Smith and the other Gainesville staff are no longer employed by the organization, while calls to the Gainesville office are being forwarded to Reston, VA. Administration of the Academy's services is now being performed by the association management firm Drohan Management Group. For information, contact Bill Drohan or the other Academy staff at (703) 787-7718; fax: (703) 435-4390, 11250 Roger Bacon Drive, #8, Reston, VA 20190. The Academy's annual meeting is still planned for June 24-26, but the location has moved from Washington, DC, to New Orleans.
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A mandatory national HIV surveillance and reporting system could be implemented as early as this summer, according to officials of the federal Centers for Disease Control and Prevention (CDC). A division among policy-makers over whether such a system should use names or unique numerical identifiers is a major sticking point that may delay implementation, reports American Health Consultants' AIDS Alert newsletter, February 1998.
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Representatives of the Hospice Association of America (HAA) and the National Hospice Organization (NHO) are working with the federal government on drafting a model corporate compliance plan for hospices. The finished plan would be published by the Office of Inspector General (OIG), while the trade associations would provide technical assistance and other materials to aid providers in implementing it. Draft language also will be published in the Federal Register for comment.
The HAA/NHO joint advisory group has begun meeting, and will base its efforts on a previously published hospital model compliance plan, explains Diane H. Jones, MSW, ACSW, HAA's executive director. "We are grateful we were given the chance to draft this language. I think OIG would like to see it done within a year," she adds. Corporate compliance plans increasingly are seen as a way for providers to anticipate and prevent possible future fraud and abuse problems with the government.
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In a short period there has been a fundamental change in the public's perception of HIV name reporting, driven primarily by the remarkable consequences of the current new paradigm in HIV treatment. New antiviral treatment regimens last year resulted in the first-ever decline in AIDS deaths and incidence. But as a result, AIDS surveillance has rapidly become an unreliable marker for identifying the frontier of new HIV infections. Not since the early years of the epidemic has AIDS surveillance been so weak, says Kevin DeCock, MD, director of CDC's division of HIV/AIDS prevention, surveillance, and epidemiology.
As a result, CDC is joining with a number of state health departments to push for implementing a mandatory national HIV surveillance system. The agency will soon publish in the Morbidity and Mortality Weekly Report the results of its evaluation of alternatives to HIV name reporting now being piloted in two states. It also plans to publish a type of "best practices" document in the Federal Register to spell out the standards for conducting HIV name reporting. AIDS advocacy organizations oppose HIV name reporting on the grounds that it could result in confidentiality breaches or drive testing underground.
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A recent article in the New England Journal of Medicine reviews the history of the "slow code" - also known as the partial, show, light blue, or Hollywood code - which is a cardiopulmonary resuscitation effort involving a deliberate attempt not to aggressively bring the patient back to life. This passive goal is accomplished by not using the full armamentarium of medical interventions or by shortening the amount of time spent on resuscitation.
"A slow code is also not one that results from the medical team's previous negotiation with the patient or the patient's family, deciding on a brief trial of defibrillation or vasopressor drugs, for example, with rapid termination of the effort if the patient is not responding," says author Gail Gazelle, MD.
While the public is virtually unaware of the practice of slow codes and there are no data on them, medical ethicists condemn them as "a kind of dishonest effort" and a practice performed without informed consent. "More disturbing still is the lack of questioning of this practice by members of the medical profession," Gazelle concludes.
Source: Gazelle G. The slow code - Should anyone rush to its defense? N Engl J Med 1998; 338(7).
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News Flash: As this issue of HMA was being wrapped up, an assisted suicide advocacy group announced that a breast cancer patient in her mid-80s had used the physician-assisted suicide provisions of Oregon's Measure 16 to kill herself.
The woman had made a tape, which was played for reporters by Compassion in Dying, on which she said, "I'm looking forward to it." She died March 24 after ingesting a lethal mixture of barbiturates and syrup, washed down with brandy, the Associated Press reported.
This is believed to be the first time that an assisted suicide under Measure 16 was made public, although the Oregonian newspaper reported that at least one other cancer patient has used the law. "This is a tragic and sad day for Oregon and the United States," said Bob Castagna, a spokesman for the Oregon Catholic Conference. "Assisted suicide has begun in the state of Oregon, to our profound regret and sorrow."
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