OIG releases model compliance plan for HHAs

The model compliance plan released Tuesday was a familiar version of the one the OIG prescribed for hospitals, but there were one or two surprises. Home health agencies must ensure their services are medically necessary, as well as verify that the physicians they work with are properly licensed. In this respect, they now will have to operate much like hospitals.

"[The plan] is voluntary guidance designed to help companies prevent fraud, waste and abuse by promoting a high level of ethical and lawful corporate conduct," says HHS Inspector General June Gibbs Brown.

The home health plan is not designed for durable medical equipment outfits, which will probably get their own plan by next spring. Another plan for third-party billers should be out in the fall, according to Brown.

The plan itself is fairly similar to its predecessors. It, too, is based on seven fundamental tenets, including implementing written policies and standards of conduct; designating a compliance committee and compliance officer; training employees in compliance; creating communications channels such as hotlines; enforcing well-publicized disciplinary guidelines; conducting internal audits; and quickly investigating and correcting violations. The home health plan also calls for providers to report violations to OIG within 60 days after an internal investigation has discovered credible evidence of a problem.

But there are some special provisions that may discomfit some HHAs. For one, OIG is thrusting responsibility for verifying medical necessity upon HHAs. "Although it is a physician who determines medical necessity, a home health agency has an obligation to ensure that services it provides are medically necessary, and should consult with physicians as appropriate for the requisite assurances," says the model plan. That could be a booby trap, says Bill Sarraille, an attorney at Arent Fox in Washington, DC. "On what basis is an HHA supposed to challenge a physician?"

In addition, an HHA is expected to take "reasonable measures" to verify that a physician has an appropriate license and hasn’t been criminally convicted, disbarred or excluded. They’re also expected to conduct criminal background checks of prospective employees and avoid dealing with parties excluded by Medicare. Yet, interestingly, OIG itself appears unsure of the ability of HHAs to devise a compliance plan, the cost of which can range from $25,000 to $500,000, depending on the size of the provider. The model plan recommends HHAs use outside contractors to help build or enhance a provider’s compliance program.

Its other recommendations include:

Pay special attention in the compliance plan to areas OIG has identified as prone to fraud. These include

- billing for services not rendered;

- billing for medically unnecessary services;

- duplicate billing;

- false cost reports;

- not returning overpayments;

- paying or receiving incentives to refer patients;

- billing for patients who are not homebound;

- overutilization or underutilization;

- inadequate care;

- insufficient documentation to back claims;

- billing for unallowable costs;

- unqualified personnel;

- backdating of nursing notes;

- falsified plans of care;

- untimely or forged physician certifications of plans of care and forged beneficiary signatures;

- high-pressure marketing;

- inadequate oversight of subcontractors;

- discriminatory admissions and discharges;

- volume-based compensation;

- hospitals referring patients to HHAs they own.

Pay special attention to areas where the HHA has already had problems. If OIG catches you again, they won’t be merciful.

Have caregivers confirm by signature that nursing notes are correct. Also include prompts on nursing note forms to encourage employees to verify homebound status. These might include questions such as, "Does the patient ever leave the home, and if so, where does he go and how often?"

Maintain a hotline, or if that’s not feasible, allow employees to report problems anonymously through drop boxes, e-mail or other means.

Include compliance as a factor when doing job reviews. Pay particular attention to potential hot spots such as claims submissions and cost reports as well as relationships with other providers that might violate the anti-kickback and Stark laws.

Conduct multilingual compliance training for employees, if need be. Training should focus on such areas as improper alteration of clinical records, patient rights and compliance with Medicare conditions of participation.

Meanwhile, OIG is taking note of criticism that the process of designing its model plans is too secretive. When creating future plans, the agency will first put a notice in the Federal Register soliciting public input on what should be included in each plan.