The OIG Audits Are Here - Specific Actions Required

  • 1,060 views
Uploaded on

Presented by Kris Mastrangelo at the Maun Lemke Revenue Summit 2013.

Presented by Kris Mastrangelo at the Maun Lemke Revenue Summit 2013.

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
    Be the first to like this
No Downloads

Views

Total Views
1,060
On Slideshare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
17
Comments
0
Likes
0

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide
  • As a result of the Affordable Care Act, CMS released a 5 part action plan (which will be outlined on the next slide) to improve nursing home safety and quality. This program has a 3 part aim, which is outlined in this graphic.The CMS Nursing Home Action Plan is based on CMS’ Three-Part Aim for improving U.S. healthcare. The Three-Part Aim comprises three objectives: 1. Improving the individual experience of care; 2. Improving the health of populations; and 3. Reducing the per capita cost of care for populations. CMS describes its Action Plan as having themes outlined in the action plan that will guide our efforts to continue progress in improving nursing home safety and quality.
  • CMS’ strategy consists of five interrelated and coordinated approaches, each of which addresses one or more of the Three-Part Aim objectives – those five approaches are listed on this slide:Enhance consumer engagement Strengthen survey processes, standards, and enforcement Promote quality improvementCreate strategic approaches through partnershipsAdvance quality through innovation and demonstrationAlthough there are many facets to the action plan, I will not be detailing it all, instead, today I will focus onlyon QAPI. The Action Plan also addresses 5-star program, Culture Change, Care Transitions, The Inappropriate use of Antipsychotics in Nursing Homes, Advancing Excellence in America’s Nursing Homes campaign, to name a few.
  • So lets talk a little bit about what nursing homes have been doing for a QA program.For over 20 years, the existing QAA regulation has specified very minimal QAA requirements and, in fact if all you did was to fulfill the letter of the law, you likely would have a very ineffective committee. The requirement has stated that that each nursing home would have a QAA committee with certain members (federally, that who is required is the director of nursing services; a physician designated by the facility; and at least 3 other members of the facility’s staff) that meets at least quarterly and that “develops and implements appropriate plans of action to correct identified quality deficiencies. This regulatory provision contains no specifications as to the means and methods taken or the action plans developed to implement the QAA regulations. QAPI changes all that. For nursing homes, the new regulation will go far beyond this relatively ambiguous existing QAA requirement and really requires facility staff to continuously work to identify and correct quality concerns as well as sustain performance improvement activities. QAPI will also introduce the idea of transparency in a nursing homes quality activities. It appears that there will be means and method for making quality activities available to other groups or agencies. Again, these laws still need to be created and approved, so the exact nature of this is not yet known.Unlike the hospital setting, QAPI will not replace QAA but rather will be in addition to the existing QAA regulation. The good news is, If you already have a good QA plan in place you are well on your way to success in QAPI.
  • QA is a process of meeting quality standards and assuring that care reaches an acceptable level. Nursing homes typically set QA thresholds to comply with regulations. They may also create standards that go beyond regulations. QA is a reactive, retrospective effort to examine why a facility failed to meet certain standards. QA activities do improve quality, but efforts frequently end once the standard is met.PI (also called Quality Improvement - QI) is a pro-active and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems. PI in nursing homes aims to improve processes involved in health care delivery and resident quality of life. PI can make good quality even better.QA and PI combine to form QAPI, a comprehensive approach to ensuring high quality care.QAPI is data driven and proactive. Its goal is to improve the quality of life, care, and services in a nursing home. The activities of a QAPI involve members of the team at all levels of the organization to identify opportunities for improvement, address gaps in systems or processes, develop and implement and improvement or corrective plan, and (and this part is very important) continuously monitor effectiveness of interventions.
  • In order to better prepare our Harmony clients for the implementation of QAPI, Harmony reached out to those QIO staff that are noted as in charge of the demonstration. It is Stratis Health (the Minnesota QIO) along with the University of Minnesota that have been contracted to lead the demonstration. Harmony corresponded with someone at Stratis Health who provided us with newsletters and prototypes of tools that have been provided to the QIO demonstration participants. I think that you will find some of this inside information pretty informative. In the October 2011 QAPI Demo Newsletter, the Question is posed: How would you summarize QAPI? The answer that is provided is that QAPI is a comprehensive, structured, and ongoing program used by nursing homes to assess and improve the quality of care and services, and multiple resident outcomes, including health and safety, quality of life, exercise of choice, and effective transitions. QAPI programs must include the ongoing, organized use of data and feedback from multiple sources, an approach to early problem identification, examination of root causes of quality issues, performance improvement projects through which designated teams examine prioritized topics in depth, attention to understanding how systems of care might affect quality outcomes, taking systemic action as needed, and involvement of all staff in the quality mission. The newsletter goes on to describe the program in a shorter version which they refer to as their “elevator speech” in which they state what is noted on this slide: QAPI is a comprehensive program by which an organization identifies problems or issues early on, develops a plan to address the root causes of problems and prevent adverse events throughout the system, and involves the entire team in using data to understand quality and work to improve performance.
  • This chart was adapted from Health Resources and Services Administration (HRSA) and shows some key differences between QA and PI efforts.It is easy to see how both are useful, and how they compliment one another very nicely. It’s also easy to see that if you only use one of the methods, you will be missing out on some key tools for quality in your organization.
  • According to Karen Schoeneman, Past Technical Director, CMS Division of Nursing Homes “QAPI is about critical thinking. It involves figuring out what is causing certain problems, and implementing interventions and solutions that address the root causes of the problems, rather than just the symptoms.” Identification of root cause of issues (whether they are care concerns for one individual or a quality issue impacting the whole facility) is not a skill that that the line staff or nursing leaders in a nursing home often get to use. Remember, this does not mean nurse managers. I’m talking about charge nurses and lead nursing assistants in the nursing home.I’d like you to think about an aspect in our culture that was once very prevalent—bed rails. When I first became a CNA in 1992 all of my patients used bedrails. The big, metal, clangy ones. The last thing I did before leaving that room was elevate those side rails. If I failed to do that, I got written up. Three times written up, I’d get fired. It was high controversy to walk into a room and find a bedrail down.Now think about chair alarms. We use them to keep the resident safe (like we used to do for bed rails). I bet in 20 years we are going to look back at a little box that set off the “whooopwhooopwhooop” every time the patient shifts in the chair, or even tries to adjust clothing around their bottom area. Or worse, the one that has a recording saying “Beckie, please sit down. Please sit down, Beckie” as a disjointed voice from the sky. Talk about hallucination-inducers. I bet we will see chair alarms as just as ridiculous as full length, metal, clangy bedrails on 100% of the patient population. Now we know better, and address the reason why the patient is climbing out of bed. I believe we are also starting to address the reason why patients want to stand up—not just putting an alarm on them.So lets think about another thing that is prevalent in nursing homes that CMS has directed us to address—the use of antipsychotic medications. We have been working on the CMS initiative to decrease antipsychotic medication use by 15% by the end of calendar year 2012 – determining the root cause of behavior issues will go a long way in decreasing the use of antipsychotic medications. Think about the importance of the team coming together to really determine the why of the behavior and then seeking to implement interventions that address that. Consider what the positive effect on the nursing home population as a whole will be if we can decrease medications that are not necessary by addressing the underlying need of the patient.
  • Here are the Five elements of a QAPI. This information has been widely publicized, and has been available for our use for a long time. We will spend our time today talking about the 12 step action plan for the implementation of your QAPI program.You will see that contained within the 12 step action plan the concept of these five elements is strong.
  • I think we have all been a part of a new program or ideal that sweeps the industry. We get excited and energized, and begin to implement the changes in full force. Unfortunately that change is not always sustained for the long haul.Another common pitfall is “change for the sake of change”, with no real improvement gleaned from all the hard work done, which can be frustrating for your staff. Lets make sure we have counted the cost and are prepared to make a change that is meaningful for the improvement of the quality and care in our nursing homes, and also that we are committed to sustaining that positive change.With QAPI your organization will use a systems approach to actively pursue quality, not just respond to external requirements.
  • A common goal of any quality model or methodology is to “meet or exceed customer expectations.” I believe that meeting the mission of the organization is really what meeting expectations is. In the January 2007 edition of Nursing Homes Magazine, Paul Willging refers to a study which states that although the mission and vision (of an organization) make sense to those who write them, fewer than 5% of regular employees understand them. How can they meet the mission if they don’t know or understand it?Performance improvement often talks about external and internal customers. External customers can be thought of as the reason an organization exists – these are the people we serve – primarily our residents and families. Other important external customers are third party payers such as the government and insurance companies, the community, health care providers, etc. An internal customer can be thought of as anyone in the organization – anyone that you provide with information, services, products, processes, or supplies. For example, if a nurse provides information to a nursing assistant so that the nursing assistant can provide care for a resident, the nursing assistant is the nurse’s internal customer. However, when the nursing assistant shares information back with the nurse, the nurse is then the customer of the nursing assistant. In reality, since we all relate to each other and provide services for each other, we have many internal customers. An organization that has a customer focus has clearly identified all customers, and all people in the organization know both the internal and external customers, and know the requirements needed to ensure their satisfaction.
  • During a PIP you will try out some changes and then see whether or not they made a difference in the area you were trying to improve. In the PLAN stage, the team learns more about the problem, plans for how improvement would be measured, and plans for any changes that might be implemented. In the DO stage, the plan is carried out, including the measures that are selected. In the STUDY phase, the team summarizes what was learned. In the ACT phase, the team and leadership determine what should be done next. The change can be adapted (and re-studied), adopted (perhaps expanded to other areas), or abandoned. That decision determines the next steps in the cycle.
  • Lets talk about the 12 step program to implementing your QAPI. These steps do not need to be done in order, but they do build on each other. The most important aspect of QAPI is effective implementation. Learning and understanding the principles is just the first step.In other words, its time to hit the GO BUTTON!
  • Lets talk about the 12 step program to implementing your QAPI. These steps do not need to be done in order, but they do build on each other. The most important aspect of QAPI is effective implementation. Learning and understanding the principles is just the first step.In other words, its time to hit the GO BUTTON!
  • Lets talk about the 12 step program to implementing your QAPI. These steps do not need to be done in order, but they do build on each other. The most important aspect of QAPI is effective implementation. Learning and understanding the principles is just the first step.In other words, its time to hit the GO BUTTON!
  • Lets talk about the 12 step program to implementing your QAPI. These steps do not need to be done in order, but they do build on each other. The most important aspect of QAPI is effective implementation. Learning and understanding the principles is just the first step.In other words, its time to hit the GO BUTTON!
  • In January 2012, the Board of Directors of Advancing Excellence announced that it will update the goals of the Campaign. The new goals will be rolled out gradually throughout 2012, and include national targets for improvement, data gathering tools and other resources to help nursing home performance improvement in nine focus areas. New materials related to the goals will be posted on the Campaign website as they are developed. Over the next few slides, I will share the goals along with the description and rationale for each of them. Some of these goals represent brand new goals whereas some are existing goals that have been revised. Recognizing that a stable workforce is fundamental to providing the highest quality care and life in nursing homes and sustaining performance improvement, this is included as an Advancing Excellence Goal. Working on this goal will provide nursing home staff with resources and tools to improve staff stability, especially by reducing staff turnover. The result will be better care for the resident and a more satisfied workforce. Working on this goal may also reduce costs that are associated with high turnover rates. Consistent Assignment lets meaningful relationships develop between the staff person and resident that in turn promotes person-centered care planning and individualization of care practices. Working on this goal will provide nursing home staff with a standard definition of consistent assignment, tips to implement consistent assignment and a method to measure it. The result will be improved relationships between staff and residents and increased quality of care and life. Person-centered care means that each resident of a nursing home has a choice about his or her daily routine, activities and healthcare. Staff places value on listening, background and personal preferences – regardless of the individual’s cognitive ability or length of stay. Certainly the MDS 3.0 has increased the personal voice of the resident and the continued growth in our abilities to gain the voice of the resident is fundamental to a providers’ ability to provide for quality of life and care.
  • Nursing home residents are often sent to the ER with exacerbations of chronic conditions as well as with new, acute illnesses. When nursing home staff are prepared and have the skills to treat residents with more serious illness on-site, residents benefit since they avoid transfer trauma and other negative consequences of hospital admissions. Working on this goal will enable staff to safely care for residents on-site using evidence-based tools and practices to reduce rates of hospitalization without compromising a resident’s well-being or wishes. Medications, when used appropriately, help promote the resident’s highest practicable mental, physical, and psychosocial well-being. Inappropriate use of medications can compromise a resident’s well-being and even cause death. Initially this goal will focus on medications that are used to control behaviors such as anti-psychotic drugs. Working on this goal will provide the nursing home staff with alternative non-pharmacological interventions for residents who otherwise would be treated with anti-psychotic medications. The result will be better health for residents. Enhancing and maintaining mobility as a part of daily care is important to maintain a person’s physical and psychological well-being. Immobility can result in complications in almost every body system, which can lead to further disability and illness. Working on this goal will help nursing home staff address mobility issues including walking, range of motion, transfer, use of restraints and prevention of falls. The result will improve the resident’s health and quality of life with more freedom of movement and more activity.
  • Nursing home residents are vulnerable to infections. Implementing key practices such as hand hygiene and careful use of antibiotics can prevent the development and spread of more complicated antibiotic resistant infections in the nursing home setting. Working on this goal will help nursing home staff use evidence-based practices to identify, monitor and decrease the number of in-house acquired infections to protect residents, as well as staff, from such harm. A pressure ulcer is a painful wound that can lead to hospitalization and even death. A pressure ulcer can be caused by increased pressure on an area, poor nutrition and hydration, lying in a wet or damp bed or having many chronic conditions. Working on this goal will help nursing home staff identify residents who are at risk of developing pressure ulcers in order to prevent their occurrence and help to identify pressure ulcers in their earliest stages to heal them quickly. The result is better care for the resident. In addition, nursing homes will reduce the high cost of care associated with pressure ulcer care. Pain is under-recognized and under-treated in the nursing homes, especially for those with cognitive impairments who may be in capable of expressing their pain. Nursing home staff are sometimes unaware of medications and other interventions that will alleviate the pain. Working on this goal will help nursing home staff identify pain symptoms, and will give staff the skills to effectively treat pain. The result will make residents more comfortable and enhance their quality of life.
  • DPOC = Directed Plan of Correction.Often with a high level survey deficiency, the department will impose the penalty of a directed plan of correction (or DPOC). The first step here is to determine what happened by conducting an Assessment of Causative Factors. When I work with a team on this process, we use a write on board and just begin listing any one piece that went wrong. This is root cause identification. It is the process we use to correct deficiencies identified on survey.This slide runs you through those steps briefly.  Very familiar to nursing management, so not much discussion needed.Next we go to Steps/Interventions Undertaken – during this step we note something to do that will address each issue identified in the first step. Next we determine Triggers/Parameters to Signal of an Evolving Problem – this is a critical step in every problem solving process – deciding how you will know that things are starting to break down – this may be morning rounds, 24 hour report, family or resident complaints and the like. Finally, determine How the Facility Will Measure the Success of its Efforts – this is often audit results.
  • The goal of a nursing home never changes: to provide the best possible care for the people who live here, and to nourish the spirit of residents and staff alike. At the same time, nursing homes are places that change every day: residents and workers come and go, staff learn better ways to deliver care, equipment is modernized, and new regulations are introduced. Thus, to do our work well means adapting to change, and continuously learning new and more effective ways of working— as individuals, as teams, and as an organization.I would like to leave you with this final thought about QAPI: Successful QAPI will not be a department, it will be a way of life in the organization.

Transcript

  • 1. The OIG Audits are Here: Specific Actions Required! Presented by: Kris Mastrangelo, President & CEO Harmony Healthcare International, (HHI)
  • 2. Harmony Healthcare International Thank You Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2
  • 3. Copyright © 2010 All Rights Reserved Harmony Healthcare International, Inc. 3 About me Kris Mastrangelo, OTR/L, LNHA, MBA Kris Mastrangelo, President and CEO, owns and operates Harmony Healthcare International, (HHI) an industry leader in Long Term Care consulting. 14,000 Medical records reviewed per year. Core Business Patient Centered
  • 4. OIG Audits How We Got Here Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 4
  • 5. Wall Street Journal, November 12, 2012 Thomas Burton, November 2012 “More intensive services were done than actually performed” “Patients could not benefit from it” “Cutting fraud” Obama Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 5
  • 6. Wall Street Journal Sample 499 claims by 245 (stays) nursing facilities 1 home reached a settlement agreement on allegations of fraudulent billing for “medically unnecessary” therapy. “More therapy during the period on which bills were based.” “Look Back Period” Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 6
  • 7. OIG Report: Claims in 2009 25% billed all claims in error 1.5 billion 26% claims not supported in the medical record 542 million in over payment “Majority” error “upcoded”* Many Ultra High * Original RUG was a higher paying RUG than the revised RUG Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 7
  • 8. OIG Report: Claims in 2009 20.30% 2.50% 2.10% 75.10% Billing Errors Issues found with skilled-nursing facilities’ Medicare claims, based on an outside review of 2009 data Properly billed Billed for a more expensive treatment than was provided Billed for a less expensive treatment than was provided Billed for a condition not covered by Medicare Source: Department of Health and Human Services Office of Inspector General Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 8
  • 9. OIG Report: Claims in 2009 Remaining, “downcoded”* Did not meet Medicare coverage requirements 47% claims, misreported information on the MDS “SNF’s commonly misreported therapy” * If the original RUG was a lower paying RUG than the revised RUG Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 9
  • 10. MedPac noted that the payment system “encourages SNF’s to furnish therapy, even when it is of little or no benefit.” 20062008 SNF’s increasingly billed for higher paying categories even though beneficiary characteristics remained largely unchanged. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 10 OIG Report: Claims in 2009
  • 11. 3 RN Nurses reviewed the claims along with the PT/OT/ST Analysis Upcoded Downcoded Both considered errors Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 11 OIG Report: Claims in 2009
  • 12. Paid $1.5 billion for these claims. This represents 5.6 percent of the $26.9 billion paid to SNFs in 2009. See Table 1 for the percentage of SNF claims that were in error and Appendix D for the confidence intervals. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 12 OIG Report: Claims in 2009
  • 13. Table 1: Percentage of SNF Claims That Were in Error - 2009 Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 13 Type of Error Percentage of SNF Claims Inaccurate RUGs 22.8% Upcoded 20.3% Downcoded 2.5% Did Not Meet Coverage Requirements 2.1% Total Error Rate 24.9% Source: OIG analysis of medical record review results, 2012 OIG Report: Claims in 2009
  • 14. SNFs billed inaccurate RUGs in 23 percent of claims. Most of these claims were upcoded; far fewer were downcoded. Claims with inaccurate RUGs amounted to a net $1.2 billion in inappropriate Medicare payments. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 14 OIG Report: Claims in 2009
  • 15. Notably, 20 percent of claims billed by SNFs had higher paying RUGs than were appropriate. In these cases, the SNFs upcoded the RUGs on the claims. For approximately half of these claims, SNFs billed for Ultra High Therapy RUGs when they should have billed for lower levels of therapy or nontherapy RUGs. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 15 OIG Report: Claims in 2009
  • 16. For 57 percent of the upcoded claims, SNFs reported providing more therapy on the MDS than was indicated in the medical record. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 16 OIG Report: Claims in 2009
  • 17. For a quarter of the upcoded claims, reviewers determined that the amount of therapy indicated in the beneficiaries’ medical records was not reasonable and necessary. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 17 OIG Report: Claims in 2009
  • 18. For example, in one case, the SNF provided the highest level of therapy to the beneficiary even though the medical record indicated that the physician refused to sign the order for therapy. In another example, the SNF provided an excessive amount of therapy to the beneficiary given her condition. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 18 OIG Report: Claims in 2009
  • 19. In another example, the SNF report on the MDS that speech therapy was provided even though the record contained an evaluation of the beneficiary concluding that no speech therapy was needed and that speech therapy had not been provided. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 19 OIG Report: Claims in 2009
  • 20. Two percent of SNF claims did not meet Medicare coverage requirements For some of these claims, beneficiaries were not eligible for SNF care, either because they did not need skilled nursing or therapy on a daily basis or because there were no physician orders for these services. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 20 OIG Report: Claims in 2009
  • 21. SNFs misreported information on the MDS for 47 percent of claims. SNFs reported inaccurate information, which was not supported or consistent with the medical record, on a least one MDS item for 47 percent of claims. For 30 percent of claims, SNFs misreported the amount of therapy that the beneficiaries received or needed. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 21 OIG Report: Claims in 2009
  • 22. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 22 MDS Category With Misreported Information Percentage of Claims Therapy (i.e., physical, occupational, speech) 30.3% Special Care (e.g., intravenous medication, tracheostomy care) 16.8% Activities of Daily Living (e.g., bed mobility, eating) 6.5% Oral/Nutritional Status (e.g., parenteral feeding) 4.8% Skin Conditions and Treatments (e.g., ulcers, wound dressings) 2.4% Source: OIG analysis of medical record review results, 2012. Note: The rows do not sum to 47 percent because some claims had more than on problem. OIG Report: Claims in 2009
  • 23. In addition, reviewers found several instances in which SNFs provided more therapy during the look back period than they did during periods that did not determine payment rates. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 23 Look Back Period
  • 24. In one example, the SNF provided 90 to 110 minutes of therapy a day to the beneficiary during the look back period; however, after that period, the SNF provided only about half that amount of therapy to the beneficiary. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 24 Therapy Minutes
  • 25. In another example, the SNF provided 50 to 55 minutes of therapy a day to the beneficiary during the look back period. It lowered the amount to 30 to 40 minutes a day during the rest of the coverage period but then raised it back to 50 to 55 minutes during the next look back period. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 25 Therapy Minutes
  • 26. For 17 percent of claims, SNFs misreported whether the beneficiaries received special care. The inaccuracies came primarily from one MDS item in this category – intravenous medication. At the time of our review, SNFs were allowed to report intravenous medication if the beneficiary received it in the hospital prior to or during the SNF stay. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 26 MDS
  • 27. For these claims, the medical records either did not indicate that intravenous medication was provided during the hospital or SNF stay or clearly contradicted that these services were provided. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 27 MDS
  • 28. For 7 percent of claims, SNFs misreported the amount of assistance beneficiaries needed with activities of daily living (e.g., bed mobility, transfers, eating, and toilet use). SNFs also misreported MDS items related to oral and nutritional status and items related to skin conditions and treatments. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 28 MDS
  • 29. SNFs did not always report the correct number of stage of skin ulcers or they reported the presence of burns or open lesions inaccurately. They also did not always correctly report skin treatments, such as surgical wound care or ulcer care. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 29 Skin
  • 30. Increase and expand reviews of SNF claims CMS should instruct its contractors to conduct more medical reviews of SNF claims. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 30 OIG Recommendations
  • 31. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 31 OIG Recommendations Use its Fraud Prevention System to Identify SNFs that are Billing for Higher Paying RUGs CMS should use its Fraud Prevention System to identify and target these SNFs.
  • 32. Monitor Compliance with the New Therapy Assessments As of October 2011, SNFs must complete a “change of therapy” assessment when the amount of therapy provided no longer reflects the RUG and an “end of therapy” assessment when therapy is discontinued for 3 days Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 32 OIG Recommendations
  • 33. CMS should instruct its MACs and RACs to closely monitor SNFs utilization of these assessments through analyses of claims data. Such analyses will identify SNFs that are using the assessments infrequently or not at all. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 33 OIG Recommendations
  • 34. Change the Current Method for Determining How Much Therapy is Needed to Ensure Appropriate Payments Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 34 OIG Recommendations
  • 35. CMS should instruct the MACs to provide education to all SNFs, as well as specific training to selected SNFs, to improve the accuracy of their MDS reporting. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 35 OIG Recommendations
  • 36. Follow up on the SNFs That Billed in Error In a separate memorandum, we will refer to CMS for appropriate action the SNFs with claims in our sample that had inaccurate RUGs or that did not meet coverage requirements. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 36 OIG Recommendations
  • 37. Appendix D: Sample Sizes, Point Estimates, and 95 Percent Confidence Intervals for Estimates Presented in the Report Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 37 Characteristic Sample Size Point Estimate 95 Percent Confidence Interval SNF claims in error in 2009 499 24.9% 19.9%-30.4% SNF claims with inaccurate RUGs 499 22.8% 18.0%-28.2% SNF claims with higher paying RUGs than were appropriate (upcoded) 499 20.3% 15.6%-25.6% Upcoded SNF claims that had an Ultra High RUG 101 48.2% 34.9%-61.7% Upcoded SNF claims in which SNFs reported providing more therapy on the MDS than was indicated in the medical record 101 56.8% 42.8%-70.2% Upcoded SNF claims in which reviewers determined that the amount of therapy was not reasonable and necessary 101 25.6% 14.6%-39.4% SNF claims with lower paying RUGs than were appropriate (downcoded) 499 2.5% 1.3%-4.5% SNF claims that did not meet Medicare coverage requirements 499 2.1% 0.7%-4.7% Total inappropriate Medicare payments for SNF claims 499 $1.5 billion $988 million- $2.0 billion Inappropriate Medicare payments in proportion to total payments to SNFs in 2009 499 5.6% 3.7%-7.6% Medicare payments for SNF claims with inaccurate RUGs 499 $1.2 billion $736 million- $1.6 billion SNF claims that had inaccurate information on the MDS 487 47.3% 41.2%-53.5% Source: Office of Inspector General medical record review, 2012.
  • 38. Compliance Audit Process Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 38
  • 39. Audit Process Significant increase in frequency of Medical Review Office of Inspector General (OIG) Reports Department of Justice (DOJ) Review Zone Program Integrity Contractor (ZPIC) Recovery Audit Contractor (RAC) Budget cuts Expect to be Reviewed Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 39
  • 40. Denial Reasons Services provided were likely clinically appropriate but the documentation did not support: Technical requirements Medical necessity The skills of a therapist were required Functional outcome Need to receive an inpatient level of care Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 40
  • 41. Technical Denial Reasons Response to Additional Documentation Request (ADR) did contain documentation requested Documentation not received within requested time frame Physician Certification not signed or missing Therapy Billing logs do not support billing Part A – MDS Assessment Part B - 8 Minute Rule Illegible documentation Hospital documentation was not submitted Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 41
  • 42. Clinical Denial Reasons Documentation did not support medical necessity Documentation does not support daily skilled intervention by a qualified therapist Documentation in the medical records must support continued progress Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 42
  • 43. Denial Reasons Reasonable and Necessary The amount, frequency and duration of services were not reasonable, given the patient’s current status ST documentation demonstrates that the therapist worked long enough with the beneficiary to develop a restorative program Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 43
  • 44. Denial Reasons Skills of A Therapist ST minutes were reduced based on clinical judgment because documentation did not support the billed minutes were reasonable and necessary. The beneficiary could not participate in self feeding during this period and required the speech therapist to assist with 100% of the feeding. Documentation did not support medical necessity and need for continued skilled therapy. Patient needs assistance and supervision. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 44
  • 45. Denial Reasons Deconditioning Skills of a therapist are not required to maintain function or improve strength and endurance Services related to activities for the general good and welfare of patients (e.g., general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation), do not constitute physical therapy services for Medicare purposes Practicing of previously taught exercises does not require the skills of a therapist Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 45
  • 46. Denial Reasons Restorative Level of Care Skilled therapy was provided when non-skilled maintenance services would have been more appropriate Restorative level of care provided Documentation supports that restorative nursing could have helped the beneficiary progress versus skilled rehabilitation services 46Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  • 47. Denial Reasons Custodial Level of Care Skilled rehabilitation and nursing services were custodial in nature and could have been met with restorative nursing, family member, or nursing provision of intermittent skilled rehabilitation and nursing services and that needs were custodial in nature and could have been met with restorative nursing, family member, or nursing assistant 47Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  • 48. Denial Reasons Prior Level of Function The therapist ignored the patient’s prior level of function and set unrealistic goals Prior level of function was illegible. Prior level of function was blank. Patient's functional level had not changed when compared to his prior level of functioning documented in the medical record Weekly nursing progress notes demonstrate that the beneficiary required the same amount of assistance (extensive assistance) prior to and after the hospital stay Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 48
  • 49. Denial Reasons Rehab Potential The medical record did not support that the condition of the patient would improve materially in a reasonable and generally predictable period of time Poor Rehab potential Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 49
  • 50. Denial Reasons Goals Goals are not functional (i.e., patient will perform 10 repetitions of upper extremity exercises with the yellow theraband) Duplication of services between disciplines Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 50
  • 51. Denial Reasons Lack of Functional Progress Gains were not significant and there was no indication of carryover of the functional task Lack of documentation relating to the patient having the potential to show significant progress No significant improvement with functional ability The outcome of therapy treatment was not documented Failure to document a complete treatment plan as outlined in Documentation Required section Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 51
  • 52. Denial Reasons Modalities Electrical Stimulation used to treat motor function disorders, such as multiple sclerosis, is considered investigational and therefore, non-covered Electrical Stimulation used in the treatment of facial nerve paralysis, commonly known as Bell’s Palsy, is considered investigational and therefore, non-covered Diathermy and Ultrasound heat treatments for the treatment of asthma, bronchitis, or any other pulmonary condition are considered not reasonable and necessary, and therefore, non- covered 52Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  • 53. Denial Reasons Cognitive Therapy The record documented a diagnosis of Alzheimer’s disease. SLP documentation does not support further significant practical improvement could be expected. Medical justification for ST services is not established Speech treatment cognition for dementia Poor progress with cognition Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 53
  • 54. Denial Reasons Inpatient Level of Care Documentation did not support the need for inpatient level of care No daily skilled care requiring a stay in the SNF Supervised level of care 54Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  • 55. Denial Reasons Medical Record Conflicts Nursing notes mostly dependent ADLs/functional tasks throughout the SNF stay. Nursing note indicated there was no improvement and fluctuation of progress with self-care tasks. MDS assessments indicate that the beneficiary's ability to perform functional tasks/ADLs did not improve from the 5-day to the 90-day assessment 55Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  • 56. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 56Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 56 Audit Process On-site Medical Record Audits
  • 57. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 57Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 57 On-site Medical Record Audits AdvanceMed Request for 160-170 medical records 14 days to submit Requesting ONLY therapy documentation Therapy staffing levels were requested AdvanceMed interviews with staff
  • 58. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 58Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 58 On-site Medical Record Audits Rehab and MDS Questions Sample therapy staff interview questions: 1. Do you feel pressure to meet your RUG levels? 2. Who has the say on discharge from therapy?
  • 59. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 59Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 59 On-site Medical Record Audits Sample MDS staff interview questions: 1. Who decides the ARD? 2. Do they provide group and concurrent treatments?
  • 60. Effective Programs Consist of: Policies and Procedures Staff Training and education Audit functions Keep apprised of Regulatory Updates Is your plan effective? Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 60 Examine Your Program
  • 61. Zone Program Integrity Contractors [ZPICs] Newest contractors in the CMS arsenal Broad mandate and, unlike the RACs are tasked with ferreting out fraud in addition to recovering overpayments Unlike RACs, they have specific investigative powers and do not need to have approval for types of issues they may investigate Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 61
  • 62. ZPICs Auditors are designed to replace the more fragmented program safeguard contractors (PSCs), which had more limited jurisdiction as to types of providers they were permitted to evaluate ZPIC contractors are broken down into seven specific geographic zones Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 62
  • 63. ZPICs - Responsibilities ZPIC responsibilities are extensive and they are charged with investigating numerous issues. Preventing fraud by identifying program vulnerabilities Proactively identifying incidents of potential fraud that exist within its service area and taking appropriate action on each case Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 63
  • 64. ZPICs - Responsibilities Investigating factual allegations of fraud made by beneficiaries, providers, CMS, OIG and other sources Exploring all available sources of fraud leads in its jurisdiction Initiating appropriate administrative actions to deny or to suspend payments that should not be made to providers where there is reliable evidence of fraud Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 64
  • 65. ZPICs - Responsibilities Referring cases to the Office of Inspector General/Office of Investigations (OIG/OI) for consideration of civil and criminal prosecution and/or application of administrative sanctions Referring any necessary provider and beneficiary outreach to the POE staff at the AC or MAC Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 65
  • 66. PSC and ZPIC Investigations have priority over RAC investigations Program Integrity Manual specifically notes that data being utilized for ZPIC reviews will be inaccessible to RAC auditors so as to prevent conflicts in investigations Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 66
  • 67. ZPICs Compensation Incentives are set forth in specific ZPIC contract with CMS Compensation based on a fixed fee plus an award fee that is determined based on performance Performance award factors: Quality of services Administrative actions Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 67
  • 68. ZPICs Auditing ZPICS have a wide discretion over the types of issues they may investigate Data analysis will play a key role in such investigations Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 68
  • 69. ZPIC Auditing The CMS Program Integrity Manual states Types of issues ZPICs will be auditing Data analysis is an essential first step in determining whether patterns of claims submission and payment indicate potential problems. Such data analysis should include simple identification of aberrancies in billing patters with a homogeneous group, or much more sophisticated detection of patterns within claims or groups of claims that might suggest improper billing or payment. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 69
  • 70. ZPIC Auditing Data analysis itself shall be undertaken as part of general surveillance and review of submitted claims, or shall be conducted in response to information about specific problems stemming from complaints, provider or beneficiary input, fraud alerts, reports from CMS, other ACs, MACs or independent government and non- governmental agencies Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 70
  • 71. ZPIC Investigations ZPICs examine: Incorrect reporting of diagnoses or procedures to maximize payments Billing for services not furnished and/or supplies not provided Billing that appears to be a deliberate application for duplicate payment for the same services or supplies, billing both Medicare and the beneficiary for the same service, or billing both Medicare and another insurer in an attempt to get paid twice Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 71
  • 72. ZPIC Investigations Altering claim forms, electronic claim records, medical documentation, etc., to obtain a higher payment amount Soliciting, offering or receiving a kickback, bribe or rebate Paying for a referral of patients in exchange for the ordering of diagnostic tests and other services or medical equipment Unbundling or “exploding” charges Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 72
  • 73. ZPIC Investigations Completing Certificate of Medical Necessity (CMNs) for patients not personally and professionally known by the provider Participating in schemes that involve collusion between a provider and a beneficiary, or between a supplier and a provider, and result in higher costs or charges to the Medicare program Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 73
  • 74. ZPIC Investigations Participating in schemes that involve collusion between a provider and a contractor where the claim is assigned The provider deliberately overbills for services, and the AC or MAC employee then generates adjustments with little or no awareness on the part of the beneficiary Billing based on “gang visits” Physician visits a nursing home and bills for 20 nursing home visits without furnishing any specific service to individual patients Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 74
  • 75. ZPIC Investigations Misrepresentations of dates and descriptions of services furnished or the identity of the beneficiary or the individual who furnished the services Billing non-covered or non-chargeable services as covered items Repeatedly violating the participation agreement, assignment agreement and the limitation amount Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 75
  • 76. ZPIC Investigations Using another person’s Medicare card to obtain Medicare care Giving false information about provider ownership in a clinical laboratory Using the adjustment payment process to generate fraudulent payments Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 76
  • 77. ZPICs Authority ZPICs have considerable latitude regarding fraud investigations and have the authority to refer cases of fraud to OIG and DOJ for civil or criminal sanctions, including the potential filing of a false claims complaint Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 77
  • 78. Strategies for Providers Critical that providers take any audit request seriously Potential for referral to the OIG or DOJ for civil monetary penalties or criminal prosecution It is important to have knowledgeable counsel to assist in reviewing the information to determine whether there is potential for serious issues Regardless if the request for information seems routine Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 78
  • 79. Strategies for Providers Be Cautious: If the audit is requesting contractual information that may implicate either Stark or the Anti-Kickback Act Such claims can give rise to an FCA complaint Consult an appropriate Billing or Financial Consultant if indicated Determine whether the claims have been submitted appropriately Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 79
  • 80. Strategies for Providers If inappropriate submissions are suspected, counsel should retain the Financial Consultant to assist in the investigation Protected by the attorney-client privilege and/or work product doctrine Often self investigation into one area exposes issues in another area. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 80
  • 81. Strategies for Providers When information is protected, the provider can make an informed decision as to the nature of the problem and devise a strategy for correction May involve self-disclosure or repayment of the funds to Medicare Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 81
  • 82. Strategies for Providers If a provider can be deemed to have voluntarily returned the funds, as opposed to have the overpayment discovered by the government (in which case not credited for self- disclosing) they may be entitled to a reduction in penalty which self- disclosure may provide Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 82
  • 83. Strategies for Providers Counsel can assist if there is an inquiry from OIG or DOJ Specifically if either issues a subpoena or investigative demand All inquiries must be escalated to the highest levels until the provider can be sure that no real problem exists Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 83
  • 84. Vernacular Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 84
  • 85. Triggering Audits State and Federal investigations ZPIC, OIG, DOJ and many other governmental entities Etiology of reviews vary UB-04 edits Diagnoses patterns ICD-9 Coding Whistleblowers Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 85
  • 86. Also known as qui tam or Whistleblower cases Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 86 False Claims
  • 87. False Claims Act Any person who (1) knowingly presents, or causes to be presented, to an officer or employee of the United States Government or a member of the Armed Forces of the United States a false or fraudulent claim for payment or approval……… Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 87 False Claims
  • 88. ……is liable to the United States Government for a civil penalty of not less than $5,000 and not more than $10,000, plus 3 times the amount of damages which the Government sustains because of the act of that person Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 88 False Claims
  • 89. Example False Claims: Billing for services of an unlicensed therapy professional Receiving payment for therapy services to patients that were not reasonable or necessary given the patients condition Corporate incentives for therapy staff to provide higher levels of care when not indicated Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 89 False Claims
  • 90. False Claims Example 1: Accused entity paid $1.5 Million for submitting claims to Medicare and Medicaid for services provided by an unlicensed speech therapist
  • 91. False Claims Example 2: Accused entity paid $953,375 for providing services that were unnecessary, and submitting claims to Medicare. For example, occupational therapy was provided to elderly Alzheimer’s patients who could never expect to return to the workforce
  • 92. False Claims Example 3: Accused entity charged with violating the False Claims Act by encouraging therapists to bill higher amounts and do more expensive therapy—even if patients didn’t need therapy or could be harmed by it. Billed nearly 68% of its Medicare Rehab days at Ultra High.
  • 93. False Claims Example 4: Accused entity paid $675,000 for submitting claims for therapy (provided by contract therapy company) that did not match the residents’ needs. The provider is suing the therapy company for negligence and breach of contract. Will the contract therapy company face government penalties - it is likely.
  • 94. Allegations Medicare Upcoding Unnecessary Therapy Treatments Systematic Scheme Medicare Fraud Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 94
  • 95. Allegations Corporate guidelines established by Operators or Directors Direct front line staff to follow internal guidelines to deliver expensive skilled therapy, OT, PT and ST that is not reasonable or necessary Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 95
  • 96. Allegations Excessive Goals Rehab Ultra High – regardless of clinical need Length of stay targets paralleling allowable benefit coverage Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 96
  • 97. Claim Submissions Five important tips to defend allegations of improper claim submission. 1. Review the Medical Records prior to submission to the governmental entity and observe if there is in fact a pattern of misconduct or false claims (i.e., minutes on therapy logs match the MDS). Do not send the medical records without reviewing every claim. It is imperative to know what the auditors will unearth. Scrutinize the charts with a cynical eye. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 97
  • 98. Claim Submissions 2.Identify the patient's functional level prior to hospitalization, on admission and upon discharge from the SNF setting. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 98
  • 99. Claim Submissions 3.Note whether or not the patient improved functionally and clinically. If the patient's status declined or stayed the same, see if the record depicts a medical justification. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 99
  • 100. Claim Submissions 4. Assess functional status versus the documentation. In some instances, the documentation may be lacking content but the gist of the medical status is transparent. If this is the case, write a summary describing the care and status. 5. Create a summary sheet of all patients reviewed including: ICD-9 coding, hospital admission diagnoses, clinically anticipated stay at the facility, certification form completion, MDS ARDs, along with the rationale for skilled coverage. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 100
  • 101. Vernacular Providers and clinicians are reacting to the abundance of publicized investigations, with a potential negative impact on patient care Therapy professionals are questioning therapeutic interventions provided as a covered service and have adopted a conservative approach so as not to create a potential overpayment situation for the SNF Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 101
  • 102. Knowledge is diluted CMS created a complex PPS reimbursement system that focuses on calculating and monitoring therapy minutes to ensure that SNFs are properly reimbursed for services provided. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 102
  • 103. Knowledge is diluted The system is so intricate that Rehabilitation Managers are consumed by minute management with attention drawn away from clinical management Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 103
  • 104. Knowledge is diluted Due to the densities of the system, the Rehabilitation Manager is the only one who understands the system Hence Rehabilitation Departments focus on minutes, categories, EOTs, COTs and schedules versus patient care Question: Do frustrated therapists that do not understand the complexities of the system fueling the Whistleblower fire? Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 104
  • 105. Knowledge is diluted Hours and hours of labor are focused on the investigation versus the normal daily tasks of patient care, company development and industry relevance Fear and chaos ensue as employees worry about losing jobs and providing for their families Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 105
  • 106. Knowledge is diluted Anxiety and paranoia bleed out of staff as they replay the time frame under scrutiny and ponder whether or not “they did something wrong”. Silent finger pointing manifest in management’s brains, while direct care providers lose confidence in the accused organization’s integrity Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 106
  • 107. Vernacular The number one goal in post-acute care, as mandated by OBRA '87, is to bring the patient to his/her highest practicable state of wellbeing. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 107
  • 108. Compliance Compliance Programs Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 108
  • 109. Compliance Program Per Federal and State laws and Federal healthcare program requirements A system of policies and procedures Monitoring and Auditing tools Communication and reporting methods Enforcement Leadership
  • 110. OIG Supplemental Guidance: “Compliance programs help nursing facilities fulfill their legal duty to provide quality care; to refrain from submitting false or inaccurate claims or cost information to the Federal health care programs; and to avoid engaging in other illegal practices”. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 110 Compliance and Ethics Program
  • 111. OIG Guidance http://oig/hhs/gov/compliance/complianc eguidance/index.asp Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 111 Be As Informed As Possible
  • 112. Compliance Is Mandatory Medicare/Medicaid Condition of Participation March 23, 2013 Patient Protection and Affordable Care Act
  • 113. HIPAA Privacy Rule Security Rule Breach Notification Rule
  • 114. Penalties: HIPAA Civil penalties: up to $50,000 per violation ($1.5 Million annual maximum per type of violation) Criminal penalties: Up to $250,000 and 10 years imprisonment
  • 115. Efficacy Criminal sanctions may be mitigated by a compliance program, but only if that program is effective Most SNFs lack the policies & procedures, staff training, audit functions, and regulatory updates to keep their compliance programs effective 115Harmony Healthcare International, Inc.
  • 116. Required Compliance Program Components Written Policies & Procedures, Code of Conduct Compliance Officer & Compliance Committee Training and Education Effective Lines of Communication Enforcement of Standards Responding Promptly to Detected Offenses and Taking Corrective Action Auditing and Monitoring 116Harmony Healthcare International, Inc.
  • 117. Risk Areas Quality of Care Resident Rights Billing & Claims Submission Employee Screening Kickbacks, Inducements and Self-Referrals Cost Reporting HIPAA Privacy and Security Record Creation and Retention Anti-Supplementation Medicare Part D 117Harmony Healthcare International, Inc.
  • 118. Baseline Audit: Identify risk areas Identify strengths and weaknesses Seek input from all departments Always be on the lookout for “new” risks 118Harmony Healthcare International, Inc.
  • 119. Periodic Audits Quality of Care Resident Rights Billing & Cost Reporting Employee Screening Kickbacks, Inducements and Self-Referrals Submission of Accurate Claims HIPAA Privacy and Security Record Creation and Retention Anti-Supplementation Medicare Part D Additional risk areas identified in the baseline audit 119Harmony Healthcare International, Inc.
  • 120. Annual Review Annual Review of the overall effectiveness of the compliance program 120Harmony Healthcare International, Inc.
  • 121. Compliance Officer Develop a position description Essential duties Oversee and monitor the implementation of a corporate compliance program Help the organization, through policies and procedures, auditing, and training, minimize the risk of fraud and abuse 121Harmony Healthcare International, Inc.
  • 122. Compliance Officer Reports to the Compliance Committee Directs facility audits Collect data Develop responsive action plans Manages compliance hotline reports Compliance training for the organization Harmony Healthcare International, Inc. 122
  • 123. Compliance Officer Manage employee, officer, contractor, and volunteer screening Oversee HIPAA compliance activity Participate in the Quality Assurance program Conduct annual compliance program review and update Ensure contractors are aware of your compliance program and resident rights123Harmony Healthcare International, Inc.
  • 124. Compliance Officer A Compliance Officer can hold another position within the organization at the same time, i.e., staff development coordinator, quality assurance nurse Requires a dynamic person will have to interact with Board members, CNAs, housekeepers, department leaders, contractors, volunteers, and regulators 124Harmony Healthcare International, Inc.
  • 125. Compliance Programs Train and educate Provide compliance training to all employees, officers, directors, owners upon hire and annually Create a training schedule for each risk area 125Harmony Healthcare International, Inc.
  • 126. Compliance Programs Audit and Monitor Develop audit tools for each risk area Schedule audits throughout the year Assign responsibility for audits Develop a reporting mechanism for audit results 126Harmony Healthcare International, Inc.
  • 127. Compliance Programs Review annually Acknowledge progress Identify areas to further advance compliance 127Harmony Healthcare International, Inc.
  • 128. Compliance Programs Stay current Monitor and incorporate updates into the Compliance Program New regulations OIG updates Recent enforcement actions 128Harmony Healthcare International, Inc.
  • 129. Compliance Programs Compliance Officer is the key to a successful program 129Harmony Healthcare International, Inc.
  • 130. Compliance QA Committee Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 130
  • 131. The CMS Nursing Home Action Plan: A Three Part Aim Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 131
  • 132. The CMS Nursing Home Action Plan: Five Approaches Enhance consumer engagement Strengthen survey processes, standards, and enforcement Promote quality improvement Create strategic approaches through partnerships Advance quality through innovation and demonstration Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 132
  • 133. F520 - Quality Assessment and Assurance (QAA) The facility has an ongoing QAA committee that includes designated key members and that meets at least quarterly; and The committee identifies quality deficiencies and develops and implements plans of action to correct these quality deficiencies, including monitoring the effect of implemented changes and making needed revisions to the action plans. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 133
  • 134. What is QAPI? The merger of two complimentary approaches to quality management: Quality Assessment – determining where things are going well and where opportunity to improve exists Performance Improvement – the reaction to the opportunity to improve Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 134
  • 135. The QAPI “Elevator Speech” QAPI is a comprehensive program by which an organization identifies problems or issues early on, develops a plan to address the root causes of problems and prevent adverse events throughout the system, and involves the entire team in using data to understand quality and work to improve performance Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 135
  • 136. What is QAPI? Quality Assurance Performance Improvement Motivation Measuring compliance with standards Continuously improving processes to meet standards Means Inspection Prevention Attitude Required , reactive Chosen, proactive Focus Outliers: “bad apples” Individuals Processes or Systems Scope Medical provider Resident care Responsibility Few All Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 136
  • 137. What is QAPI? “QAPI is about critical thinking. It involves figuring out what is causing certain problems, and implementing interventions and solutions that address the root causes of the problems, rather than just the symptoms” Karen Schoeneman Past Technical Director, CMS Division of Nursing Homes Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 137
  • 138. QAPI: The Five Elements 1. Design and Scope 2. Governance and Leadership 3. Feedback, Data Systems and Monitoring 4. Performance Improvement Projects (PIPs) 5. Systematic Analysis and Systemic Action Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 138
  • 139. The Challenge… “Not all change is improvement, but all improvement is change” Donald Berwick, MD Former CMS Administrator Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 139
  • 140. The Goal of QAPI and/or Other Quality Improvement Models The Goal: Meet or exceed the expectations of our customers Meeting customer expectations = meeting the mission! Who are the customers? External customers: The reason the organization exists Internal customers: Anyone within the organization Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 140
  • 141. The Model for Improvement Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 141
  • 142. The 12 Action Steps to QAPI The 12 steps do not need to be achieved sequentially, but each step builds on other QAPI principles The most important aspect of QAPI is effective implementation Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 142
  • 143. The 12 Action Steps to QAPI Step 1: Leadership Responsibility and Accountability Step 2: Develop a Deliberate Approach to Teamwork Step 3: Take your QAPI “pulse” with a Self-Assessment Step 4: Identify your Organization’s Guiding Principles Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 143
  • 144. The 12 Action Steps to QAPI Step 5: Develop your QAPI Plan Step 6: Conduct a QAPI Awareness Campaign Step 7: Develop a Strategy for Collecting and Using QAPI Data Step 8: Identify your Gaps and Opportunities Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 144
  • 145. The 12 Action Steps to QAPI Step 9: Prioritize Quality Opportunities and Charter PIPs Step 10: Plan, Conduct, and Document PIPs Step 11: Getting to the “Root” of the Problem Step 12: Take Systemic Action Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 145
  • 146. Advancing Excellence in America’s Nursing Homes - Goals for 2012 Improve staff stability Increase use of consistent assignment Increase person-centered care planning and decision making Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 146
  • 147. Advancing Excellence in America’s Nursing Homes - Goals for 2012 Reduce hospitalizations safely Use medications appropriately Increase resident mobility Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 147
  • 148. Advancing Excellence in America’s Nursing Homes - Goals for 2012 Prevent and manage infections safely Reduce pressure ulcers Decrease symptoms of pain Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 148
  • 149. The DPOC Model: Great for Problem Solving Assessment of causative factors Steps/interventions undertaken Triggers/parameters to signal of an evolving problem How the facility will measure the success of its efforts Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 149
  • 150. QA Committee “Excellence is an art won by training and habituation. We do not act rightly because we have virtue or excellence, but we rather have those because we have acted rightly. We are what we repeatedly do. Excellence, then, is not an act but a habit.” -AristotleCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 150
  • 151. QA Committee The goal of providing the best possible quality of care and life for those entrusted to our care does not change Success depends on us evolving and always striving to redefine and achieve excellence Successful QAPI will not be a department, it will be a way of life in the organization Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 151
  • 152. Identify areas of exposure Identify areas of strength Highlight weak areas and prioritize solutions Seek interdisciplinary participation Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 152 Conduct Baseline Audits
  • 153. Compliance Care Centered Patient Advocates Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 153
  • 154. Conclusion Educate, Discuss and Prepare Define Medicare Medical Review Communicate to all Staff Medicare Skilled Care Criteria Conduct internal/external Mock Audits to educate staff Refine Interdisciplinary Management of Medicare Appeals Harmony Healthcare International, Inc. 154Copyright © 2012 All Rights Reserved
  • 155. Sources Public Law 108-173, 117 STAT. 2066 Public Law 109-432, 120 STAT. 2922 www.dcsrac.com/IssuesUnderReview.aspx Program Integrity Manual John v Sebelius, No. 4:09-CV-00552 (E.D. Ark. 10/6/10) 42 C.F.R. Chap. 1136 (f) Richardson v. Perales, 402 U.S. 389 (1971) Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 155
  • 156. Questions/Answers Harmony Healthcare International (978) 887 - 8919 www.Harmony-Healthcare.com Connect with Us! @KrisMastrangelo @Harmonyhlthcare facebook.com/HarmonyHealthcareInternational H linkedin.com/company/harmony-healthcare 156Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.
  • 157. Harmony Healthcare International Have you Considered a Customized Complimentary HARMONY(HHI) MEDICARE PROGRAM EVALUATION or CASE MIX ANALYSIS for your Facility? Perhaps your facility has potential for additional revenue Benchmark your facility against key indicators and national norms Email us at for more information RUGS@harmony-healthcare.com Harmony Healthcare International, Inc. 157Copyright © 2013 All Rights Reserved