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Study current policies and follow OIG standards
The vast majority of hospices are small organizations that spend most of their resources providing care to their patients. Administration is thin, and their budgets don’t allow for additional administrative staff. So when Medicare’s Office of Inspector General (OIG) strongly suggests hospices implement a compliance program, complete with a compliance officer, does this mean small hospices have to sacrifice a clinical position to fill an administrative one?
Even the OIG recognizes the burden an added administrative position places on hospices, especially small and medium-sized ones. While the agency stresses the importance of having a compliance officer within the organization, it has said the position can be added to the job responsibility of an existing position.
But which person in your organization is
in the best position to assume this important responsibility? Ideally, hospices want to appoint a compliance officer who is among the organization’s leaders and has direct access to the top administrator and the board of directors, says Mickey Pope, RN, BSN, corporate compliance officer for Hospice of the Bluegrass in Lexington, KY.
People in charge of quality management, risk management, or data management are good candidates for the post, says Pope, who is also the director of quality assurance.
"It seemed logical to make me the compliance officer, because I report directly to the president, and I can also bypass the president and go directly to the board," Pope says.
People in the positions mentioned above bring a broad perspective of hospice to the position, monitor problems within the organization, and have experience in implementing change when needed, adds Pope.
Hospices shouldn’t make the mistake of making people with accounting backgrounds the heads of compliance programs, says David Queen, JD, a Baltimore-based attorney who handles fraud cases for home health and hospice providers. While accounting skills are valuable, they represent a small portion of overall job responsibilities. Instead, Queen says, compliance chiefs should have a human relations background and management skills.
"You need someone who is able to interact with both employees and upper management," Queen says.
Whether full-time or part-time, the primary responsibilities of the compliance officer should include:
• monitoring implementation of the compliance program;
• certifying that employees have received, read, and understood the standards of conduct;
• developing the education and training programs to ensure staff are knowledgeable of not only organizational policies but state and federal standards as well;
• investigating and acting on matters related to compliance, such as suspected violations.
Once a hospice has tapped one of its administrative staff to assume the position of compliance officer, that person becomes the organization’s leader for implementation of a compliance program. And this is no small task.
Pope identifies the following steps a compliance officer must complete or oversee:
• Become educated in OIG’s compliance guidelines.
• Assemble a compliance committee composed of key members of the organization, including the vice president of clinical services, director of finance, human resources, and the administrator.
• Inform the board of directors of the hospice compliance program plan, and keep the board updated on progress.
• Educate staff with a series of inservices that inform them about the policies within the compliance program and assure them that the policies are not the result of current problems and that no one is the target of fraud and abuse scrutiny.
Avail yourself of OIG’s guidance
All of the above points are part of an overall plan to implement a compliance program. One important point not mentioned above is the development of policies and procedures that will illustrate how a hospice approaches potential fraud and abuse. The hospice compliance officer should consult the OIG’s guidance, which can be found at the OIG’s Web site at www.oig.gov.
Among the key elements the OIG looks for in a compliance program elements are:
• development and implementation of
effective training and education programs;
• development and maintenance of effective lines of communication;
• enforcement of standards through well-publicized disciplinary guidelines;
• use of audits and other evaluation techniques to monitor compliance;
• development of procedures to respond to detected offenses and initiate corrective action.
Compliance officers must spearhead a hospicewide effort to review current policies and procedures, compare them to OIG guidance, and adjust, change, or add policies to ensure the program mirrors OIG’s expectations.
"We came up with a whole list of policies that needed to be amended," Pope notes.
Hospices might consider using the compliance guidance as a checklist so as to ensure every standard is met. Important standards include the following:
• Are the standards of conduct applicable to all affected employees and independent contractors?
• Do the standards of conduct articulate the hospice’s commitment to comply with all federal, state, and private insurer standards, with an emphasis on preventing fraud and abuse?
• Are the standards of conduct distributed to all employees?
• Do policies and procedures require proper/ timely documentation of the specific clinical
factors that qualify a patient for the Medicare Hospice Benefit?
• Has the hospice created an oversight mechanism to ensure that the terminal illness of a Medicare beneficiary is verified?
• Do written policies and procedures require that before a patient is admitted for hospice services, the hospice physician and attending physician thoroughly review and certify the admitting diagnosis and prognosis?
• Does the hospice take all reasonable steps to ensure that the written plan of care is established and maintained for each individual who receives hospice care?
• Does the hospice monitor and evaluate its resource allocation regularly to identify and resolve problems with the utilization of services, facilities, and personnel?
• Has the hospice implemented policies and procedures to identify, assess, and rectify problems associated with the appropriateness of interdisciplinary group services and the level of services being provided?
• When a nursing home resident elects the Medicare Hospice Benefit, do the hospice and nursing home jointly establish a coordinated plan of care that reflects the hospice philosophy and is based on an assessment of the individual’s needs and unique living situation in the nursing home?
• Do the policies and procedures require that all of the hospice’s contracts and arrangements with actual or potential referral sources be reviewed carefully for compliance with all applicable statutes and regulations?
The above standards only represent a fraction of the standards the OIG has established for hospice compliance programs. Reviewing policies and creating new ones is a time-consuming process. Pope says Hospice of the Bluegrass started its program implementation in November 1999 and had it completed for employee education by June 2000.
"It takes so much time and follow-up," says Pope. "You really have to give it most of your attention."
In the eyes of the federal government, a compliance program brings numerous benefits to its users, not the least of which is the ability to identify weaknesses in internal systems and management. Those who have effective compliance programs in place will have, in the opinion of federal officials:
• safeguards that will identify and prevent illegal or unethical behavior;
• a view of expected employee and contractor behavior relating to fraud and abuse;
• a document that demonstrates to the government and public that the hospice is committed to honest provider and corporate conduct.
Putting the plan in motion
Once the standards have been met and policies established, it’s time to begin educating workers about their roles in keeping the organization compliant.
Training sessions should be spearheaded by the compliance officer who must highlight the hospice’s compliance program, summarizing fraud and abuse laws, federal health care program requirements, claim development and submission processes, and patient rights. Training should not be limited to hospice employees, but should include physicians contractors and other agents.
Based on the home health compliance program guidelines, the OIG is likely to recommend that hospices require a minimum number of educational hours per year as a condition of employment. It may also recommend that an employee’s failure to attend training should lead to disciplinary action, including termination.
There should be an open line of communication between employees and the compliance officer. The OIG may suggest that written confidentiality and nonretaliation policies be developed to encourage employees to report potential fraud. The process of communication needs to be clear among employees to prevent confusion when reporting potential fraud. These lines of communication can take several forms, such as hotlines, e-mails, written memos, and suggestions boxes, to name a few.
An effective compliance program will include clear disciplinary guidelines for officers, managers, and employees who violate policies and standards of conduct. The OIG says compliance programs for all health care settings need to set forth the degrees of disciplinary action and ensure that workers are aware of the consequences of illegal
or unethical behavior.
There should be an ongoing evaluation process to ensure compliance. The OIG suggests performing regular audits by internal or external examiners who have an expertise in state and federal health care program requirements. According to past guidelines, OIG has recommended that the minimum scope of audits include laws governing kickback arrangements, physician self-referral, claim development and submission, reimbursement, cost reporting, and marketing.
Procedures for investigating suspected abuse should take into account the possibility that a single incident may be indicative of a systematic problem. Procedures may include bringing in outside counsel, auditors, or other health care experts to assist in the investigation. The compliance officer also is responsible for reporting misconduct to the proper authorities along with evidence uncovered during the internal investigation. The reporting of misconduct will be considered a mitigating factor in OIG’s determination of administrative sanctions.