“Why, How, What: Compliance,
Operations & Reimbursement –
The Circle of Safety”
HARMONY UNIVERSITY
The Provider Unit of
Ha...
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc.
About Elisa
Elisa Bovee, MS OTR/L
Elisa Bovee ...
Objectives
The learner will be able to:
Summarize the OIG Report and the significant impact on
the SNF setting
State the l...
OIG AUDIT
The Significant Impact on SNF
Providers
Wall Street Journal,
November 12, 2012
Thomas Burton, November 2012
“More intensive services were done
than actually perfo...
Wall Street Journal
Sample 499 claims by 245 (stays)
nursing facilities
1 home reached a settlement agreement
on allegatio...
OIG Report:
Claims in 2009
25% billed all claims in error: 1.5 billion
26% claims not supported in the
medical record
542 ...
OIG Report:
Claims in 2009
20.30%
2.50%
2.10%
75.10%
Billing Errors
Issues found with skilled-nursing
facilities’ Medicare...
1. Increase and expand reviews of SNF claims
CMS should instruct its contractors to conduct more medical reviews of
SNF cl...
4. Change the Current Method for Determining How
Much Therapy is Needed to Ensure Appropriate
Payments
5. CMS should instr...
Utilize this site as a resource for
educating the team on Compliance
Program expectations of the
government.
https://oig.h...
Probe Reviews and RAC Audits
Program for Evaluating Payment Patterns
Electronic Reports
(PEPPER)
Copyright © 2014 All Righ...
PEPPER
This report will contain the SNFs detailed
facility specific Medicare claims data in certain
targeted areas and com...
Where is My Pepper?
Updated Release Schedule: On or about
May 6 through May 12, 2014
Staged Release
Freestanding SNFs will...
Accessing Your SNF PEPPER
Access to the PEPPER will be restricted
to the provider’s Chief Executive Officer,
President or ...
Accessing Your SNF PEPPER
What you will need:
Facility specific 6-digit CMS Certification Number
The 3rd digit of this num...
Accessing Your SNF PEPPER
For verification purposes, requestors will be
required to enter either one of the following from...
PEPPER
Targeted areas were derived from two
recent Office of Inspector General (OIG)
Reports:
“Inappropriate Payments to S...
Fraud, Waste and Abuse
The Government Accountability Office
has designated Medicare as a program at
high risk for fraud, w...
Compliance
The Office of Inspector General encourages SNFs
to develop and implement a compliance program
to protect their ...
Compliance
The Program for Evaluating Payment
Patterns Electronic Report (PEPPER)
can help guide the SNF’s auditing and
mo...
PEPPER
PEPPER gives provider-specific Medicare
data statistics for services vulnerable to
improper payments
Allows provide...
Claims Data
The SNF PEPPER provides SNFs with their
jurisdiction, state and national percentile values
for each target are...
Claims Data
Claim “From Date” and claim “Through
Date” fall within the time period of
October 1, 2010 through September 30...
Target Areas
Therapy RUGs with High ADLs
Nontherapy RUGs with High ADLs
Change of Therapy Assessment
Ultra High RUGs
Thera...
Percentiles
Percentiles are calculated for each of the three comparison
groups
State
Medicare Audit Contractor (MAC/FI) ju...
Target Area Reports
Target area graph provides a visual representation of
the SNF’s target area percent over three years
T...
Comparative Data-FY2013
Target Area
20th
Percentile
50th
Percentile
80th
Percentile
Therapy RUG Days 85.5% 93.2% 97.3%
Ult...
Facility Specific Risk Factors
Focus on National Data
Risk Assessment
Review areas approaching or at outliers
(80th Percen...
HHI Analysis
FY 2013 PEPPER ANALYSIS
Harmony Healthcare International (HHI)
430 Boston Street, Suite 104, Topsfield, MA 01...
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Therapy RUG
Days
Ultra High
RUG Days
Therapy High
ADL Days
Non-Therapy
High AD...
Actual SNF
20th
Percentile
50th
Percentile
80th
Percentile
72.8% 85.5% 93.2% 97.3%
58.5% 28.1% 53.9% 73.1%
51.6% 20.0% 32....
Concluding Thoughts on PEPPER
There is no “Good” or “Bad” PEPPER
Compliance chart auditing at regular
intervals for outlie...
Concluding Thoughts on PEPPER
PEPPER is a Tool for Ensuring
Compliance with High Risk Areas
Accurate and Appropriate Reimb...
Identify areas of exposure
Identify areas of strength
Highlight weak areas and prioritize
solutions
Seek interdisciplinary...
Introduction to Healthcare
Compliance for the SNF
Copyright © 2014 All Rights Reserved Harmony Healthcare International, I...
In 2012, the government received the highest
amount of whistleblower complaints in its
history
This, combined with the adv...
Critical changes have occurred with the
False Claims Act
Most noteworthy change; Leaders be
advised!
Revision of the "inte...
Historically, proof of "intent" was
required to prosecute
Today, no proof or specific intent to
defraud is required
Harmon...
The government only needs to show:
1. The provider had "actual knowledge of the
information" or
2. The person acted in "de...
Providers have only 120 days to correct MDS
errors and submit a billing adjustment for
Medicare Part A claims
Late identif...
The only defense for an incorrect claim is a
great offense in the form of an effective
Compliance Program
Harmony Healthca...
The following 7 elements are outlined for your
success:
1. Written Policies and Procedures
2. Compliance Officer, Committe...
Compliance Programs
The Office of Inspector General encourages SNFs
to develop and implement a compliance program
to prote...
Compliance Programs
Beginning March 2013, SNFs are required to
have a compliance program
OIG has determined seven elements...
Compliance Programs
“Superficial efforts or programs that are
hastily constructed and implemented
without a long term comm...
Cost of Compliance Program
An effective compliance program may
require a reallocation of existing
resources
The long term ...
Cost of Non-Compliance
$305,072 was required to hire a full-time physician or
NP after it was found to have sub-standard p...
Benefits of Compliance
Formulation of effective internal controls to ensure
compliance with statutes, regulations and rule...
Benefits of Compliance
Improvement in the quality, efficiency, and
consistency of providing services
Establish a mechanism...
Benefits of Compliance
Early detection and reporting,
minimizing loss to the Government from
false claims, and thereby red...
Seven Elements of Compliance
Policies and Procedures
Reporting and Investigating
Education and Training
Prevention and Res...
Creating and Enforcing
Policies and Procedures
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc....
Policies and Procedures
The development and distribution of
written standards of conduct
Policies, procedures and protocol...
Policies and Procedures
Set expectations in easily read
language
Living documents that do not collect
dust on the shelf
Fu...
Policies and Procedures
Policy: Statement of Approach
Procedures: Steps to Achieve
The development and distribution of wri...
Policies and Procedures
Code of Conduct
Provides expectations
Practical Guidance
Accountability
Copyright © 2014 All Right...
Policies and Procedures
Best practice & policy and procedure for:
MDS Completion
MDS Accuracy
ADL Accuracy
Nursing Documen...
Compliance Officer
and
The Board
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 59
Compliance...
Program Oversight
Choosing the Right Compliance
Officer
High Level Executive, credible, integrity
Authority and resources ...
Program Oversight
Oversight of Compliance
Officer/Committee
“charged with the responsibility for
developing, operating and...
Program Oversight
Communicate High Risk Areas to Staff
Employees
Contract Providers
Communicate Plan to ensure
compliance
...
Education and Training
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 63
Education and Training
#1 Reason for Non-compliance is lack
of training
Facility Compliance process
Risk Areas identified ...
Education and Training
Easy to understand focused education
Risk Areas
ADL Documentation
Therapy Documentation
Therapy Min...
Education and Training
The goal is to yield change in behavior
Employees to make the right choices
Practical and effective...
Education and Training
Internal Controls
Preventative
Detective
Directive
Copyright © 2014 All Rights Reserved Harmony Hea...
Education and Training
“The development and
implementation of regular, effective
education and training programs.”
Copyrig...
Communication
Reporting and Investigating
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 69
C...
Communication
Establish a code of conduct prioritizing
compliance
OIG requires “effective line of communication
between th...
Communication
Employees and Stakeholders require an
anonymous system to seek guidance and
report violations
Hot line
Log a...
Communication
Fact finding before full investigation
May require a management solution vs. an investigation
Once identifie...
Reporting and Investigating
Includes an Anonymous System
Non-Retaliation Philosophy to report
concerns
Investigate all con...
Identification of Non-Compliance
Respond
MDS Corrections within 120 Days of Billed Date
Billing Adjustments
Staff Concerns...
Enforcement, Discipline and
Incentives
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 75
Comp...
Enforcement and Discipline
Employees must abide by:
The law
Code of Conduct
Compliance Program stipulations
Employees have...
Enforcement and Discipline
Investigate promptly and thoroughly
Professionalism
Consistency with discipline
Reflect the sev...
Enforcement and Discipline
Define disciplinary standards for the
organization
Document all disciplinary actions
taken
Eval...
Incentives
Ethical incentives consistent with the
organization’s compliance program
Creative incentives
Often cash and cas...
Enforcement, Discipline and Incentives
Follow Policies
Consistent Discipline
Incentives to be Compliant
Copyright © 2014 A...
Auditing and Monitoring
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 81
Compliance Programs
Focus on Compliance
Auditing and Monitoring
“The use of audits and/or other risk
evaluation techniques to monitor
complian...
Auditing and Monitoring
Monitoring
Common management tool
Determines how effective the controls are
Know what is happening...
Auditing and Monitoring
Auditing
Completed by someone with no vested
interest
The higher the level of independence an audi...
Auditing and Monitoring
Auditing
Internal audit is NOT the control
Internal audit tests and evaluates the
controls
Copyrig...
Auditing and Monitoring
As part of a compliance program, a SNF
should conduct regular audits to ensure
services provided a...
Auditing and Monitoring
Monitoring
Common Management tool
Determines how effective the controls are
Helps facility or corp...
Auditing and Monitoring
Auditing
Completed by someone with no vested
interest
Formalized Approach
Established approach
Met...
Response and Prevention
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 89
Compliance Programs
Response and Prevention
Respond to reports
Root cause analysis
Provide education in risk areas
Develop policy and procedur...
Enforcement and Discipline
Investigate promptly and thoroughly
Professionalism
Consistency with discipline
Root Cause Anal...
Risk Assessment
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 92
Compliance Programs
Risk Assessment
Identify
Measure
Prioritize
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 93
High Risk Areas
Quality of Care
Resident Rights
Billing & Claims Submission
Employee Screening
Kickbacks, Inducements and ...
Risk Assessment
Determine risk areas
Prioritize on severity, likelihood and impact
Ongoing assessment
Best Practice
Change...
Secrets to Success
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 96
Compliance Programs
Appoint Compliance Officer/Committee
High level executive to oversee compliance
program
Reports directly to the top
Author...
Communication
Introduce Compliance Officer
Present Code of Conduct
Educate staff on Compliance Program
Development and Pla...
Complete a Risk Assessment
Determine Risk areas
Develop an Annual Plan
You Can’t Do It All
Prioritize
Prioritize on severi...
Complete a Risk Assessment
Prioritize likelihood
Staff Turnover in Key Roles
Changes in Federal/State Policy
OIG Reports
P...
Pick a Starting Point
Program for Evaluating Payment
Patterns Electronic Report (PEPPER)
Therapy RUGs with High ADLs
Non-t...
Analyze and Plan
Identify a point staff member for identified risk area
Policy and Procedure Review
Update/Create
Educatio...
Enforcement, Discipline and Incentives
Consistent Enforcement
Role Model
Prompt Discipline
Human Resources involvement
Adv...
Keys to Success
Provide clinically appropriate care
Document
Medical necessity
Deficits
Outcomes
Meet technical requiremen...
Bibliography
Office of Inspector General, U.S. Department of Health and Human
Services (OIG) “Inappropriate Payments to Sk...
Harmony Healthcare International (HHI)
For attending this seminar, you are eligible
for one of the following:
Free PEPPER ...
Questions/Answers
Harmony Healthcare International
(978) 887 - 8919
www.Harmony-Healthcare.com
Connect with Us!
@elisabove...
Upcoming Seminars & Webinars
Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc.
A Hands on Approach...
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 109
Register online
http://info.harmony-health...
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 110
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Why, How, What: Compliance, Operations & Reimbursment - The Circle of Safety

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This presentation discusses the key elements of a Corporate Compliance program allowing an organization to self-monitor operations on an ongoing basis to ensure compliance with supportive documentation to adhere to applicable laws and the organization’s own policies and procedures.

Appropriate for CEOs, CFOs, Administrators, Nursing Management, Direct Care Nurses in a SNF, MDS Coordinators and Business Office Managers.

Published in: Economy & Finance, Business
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Why, How, What: Compliance, Operations & Reimbursment - The Circle of Safety

  1. 1. “Why, How, What: Compliance, Operations & Reimbursement – The Circle of Safety” HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Elisa Bovee, MS OTR/L Vice President of Operations
  2. 2. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. About Elisa Elisa Bovee, MS OTR/L Elisa Bovee is the Vice President of Operations at Harmony Healthcare International, (HHI) an industry leader in Long Term Care consulting. Over 20 years of experience in the long-term care industry Appeals Coordinator for a National nursing home company Follow Me! @ElisaBovee 2
  3. 3. Objectives The learner will be able to: Summarize the OIG Report and the significant impact on the SNF setting State the latest compliance risks the OIG is targeting in long term care organizations State three ways to use data analysis and auditing methodologies to address risks and keep the organization compliant Utilize strategies for maintaining a current compliance program State the intent and practical application of the Jimmo Settlement Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 3
  4. 4. OIG AUDIT The Significant Impact on SNF Providers
  5. 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 © 2014 All Rights Reserved Harmony Healthcare International, Inc. 5
  6. 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 © 2014 All Rights Reserved Harmony Healthcare International, Inc. 6
  7. 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 © 2014 All Rights Reserved Harmony Healthcare International, Inc. 7
  8. 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 © 2014 All Rights Reserved Harmony Healthcare International, Inc. 8
  9. 9. 1. Increase and expand reviews of SNF claims CMS should instruct its contractors to conduct more medical reviews of SNF claims 2. 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 3. 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 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 © 2014 All Rights Reserved Harmony Healthcare International, Inc. OIG Recommendations 9
  10. 10. 4. Change the Current Method for Determining How Much Therapy is Needed to Ensure Appropriate Payments 5. 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 6. Follow up on the SNFs that Billed in Error In a separate memorandum, we will refer to CMS for appropriate action for the SNFs with claims in our sample that had inaccurate RUGs or that did not meet coverage requirements Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. OIG Recommendations 10
  11. 11. Utilize this site as a resource for educating the team on Compliance Program expectations of the government. https://oig.hhs.gov/compliance/ http://oig.hhs.gov/authorities/docs/cpgnf.pdf https://oig.hhs.gov/compliance/compliance- guidance/docs/complianceguidance/nhg_fr.pd f Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. OIG Website 11
  12. 12. Probe Reviews and RAC Audits Program for Evaluating Payment Patterns Electronic Reports (PEPPER) Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 12
  13. 13. PEPPER This report will contain the SNFs detailed facility specific Medicare claims data in certain targeted areas and compare the SNF to other SNFs nationally Skilled Nursing Facilities (SNFs) should sign up to receive email notification that your PEPPER is available PEPPERResources.org from the PEPPER HELP Desk (http://pepperresources.org/HelpContactUs.aspx) Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 13
  14. 14. Where is My Pepper? Updated Release Schedule: On or about May 6 through May 12, 2014 Staged Release Freestanding SNFs will receive via a secure portal on the PEPPERresources.org website SNFs/Swing beds that are part of a short-term acute care hospital (3rd digit in the PTAN/CMS certification number/provider number = “U”) will receive electronically via QualityNet secure file exchange Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 14
  15. 15. Accessing Your SNF PEPPER Access to the PEPPER will be restricted to the provider’s Chief Executive Officer, President or Administrator Corporate offices and/or facility management companies will need to obtain PEPPERs from each individual provider in their organization Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 15
  16. 16. Accessing Your SNF PEPPER What you will need: Facility specific 6-digit CMS Certification Number The 3rd digit of this number will be a 5 or a 6 This is not the same number as the tax identification number or national provider identification number Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 16
  17. 17. Accessing Your SNF PEPPER For verification purposes, requestors will be required to enter either one of the following from the UB-04 for a fee-for-service Medicare patient who received services at the provider between September 1-30, 2013: A Patient Control Number (found at form locator 03a on the UB04 claim form) or A Medical Record Number (found at form locator 03b on the UB04 claim form) Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 17
  18. 18. PEPPER Targeted areas were derived from two recent Office of Inspector General (OIG) Reports: “Inappropriate Payments to Skilled Nursing Facilities cost Medicare more than a Billion Dollars in 2009” (November 2012) “Questionable Billing by Skilled Nursing Facilities” (December 2010) Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 18
  19. 19. Fraud, Waste and Abuse The Government Accountability Office has designated Medicare as a program at high risk for fraud, waste and abuse Payments to skilled nursing facilities (SNFs) have been identified as vulnerable to abuse In 2012 the Office of Inspector General (OIG) found that approximately 25% of SNF claims were billed in error Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 19
  20. 20. Compliance The Office of Inspector General encourages SNFs to develop and implement a compliance program to protect their operations from fraud and abuse Beginning in 2013, SNFs are required to have a compliance program As part of a compliance program, a SNF should conduct regular audits to ensure services provided are necessary and that charges for Medicare services are correctly documented and billed Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 20
  21. 21. Compliance The Program for Evaluating Payment Patterns Electronic Report (PEPPER) can help guide the SNF’s auditing and monitoring activities There is no “Good” or “Bad” PEPPER Facility Specific Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 21
  22. 22. PEPPER PEPPER gives provider-specific Medicare data statistics for services vulnerable to improper payments Allows providers to see how their facility compares to all other SNFs: Nation Medicare Administrative Contractor (MAC) State (MAC only) Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 22
  23. 23. Claims Data The SNF PEPPER provides SNFs with their jurisdiction, state and national percentile values for each target area with reportable data for the most recent three fiscal years FY 2013 (October 1 2012 through September 30th 2013 ) is displayed on the first table When the target (numerator) count is less than 11 for a target area for a time period, statistics are not displayed Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 23
  24. 24. Claims Data Claim “From Date” and claim “Through Date” fall within the time period of October 1, 2010 through September 30, 2013 Additional claims for June 1, 2010 through September 30, 2010 will be included for episodes of care beginning prior to the reporting period Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 24
  25. 25. Target Areas Therapy RUGs with High ADLs Nontherapy RUGs with High ADLs Change of Therapy Assessment Ultra High RUGs Therapy RUGs 90+ Day Episodes of Care Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 25
  26. 26. Percentiles Percentiles are calculated for each of the three comparison groups State Medicare Audit Contractor (MAC/FI) jurisdiction Nation SNF are to focus on National Data Given the MAC may potentially use data for Additional Documentation Requests (ADR) reviews, all data is important SNFs whose target percents are at or above the 80th percentile (i.e., in the top 20 percent) are considered at risk for improper Medicare payments with areas at risk for over coding SNFs whose target percents are at or below the 20th percentile (i.e., in the bottom 20 percent) are considered at risk for improper Medicare payments with areas at risk for undercoding Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 26
  27. 27. Target Area Reports Target area graph provides a visual representation of the SNF’s target area percent over three years Target Area SNF Data Table titled “Your SNF” includes total number of episodes of care for the target area (numerator) and total (denominator) Roughly correlates to Patients Episodes Based on the definition of the target area Comparative Data for National, State and Jurisdiction Some include 80th and 20th Percentile Some only include 80th percentile Average Length of Stay for the numerator and for the denominator Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 27
  28. 28. Comparative Data-FY2013 Target Area 20th Percentile 50th Percentile 80th Percentile Therapy RUG Days 85.5% 93.2% 97.3% Ultra High RUG Days 28.1% 53.9% 73.1% Therapy High ADL Days 20.0% 32.9% 48.1% Non-Therapy High ADL Days 11.5% 23.4% 42.2 90+ Day Episode of Care 7.5% 14.1% 25.9% Change of Therapy Assessments 7.0% 12.7% 19.0% Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 28
  29. 29. Facility Specific Risk Factors Focus on National Data Risk Assessment Review areas approaching or at outliers (80th Percentile, 20th Percentile) Discuss with the team facility characteristics that may lead to High/Low Utilization target areas Does the data make sense Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 29
  30. 30. HHI Analysis FY 2013 PEPPER ANALYSIS Harmony Healthcare International (HHI) 430 Boston Street, Suite 104, Topsfield, MA 01983 MAC: NHIC Percentile Ranking Target Areas Target Count Percent National Jurisdiction (MAC) State Therapy High ADL Days 2,730 51.6% 85.30 82.70 83.10 Non-Therapy High ADL Days 528 26.7% 58.30 46.10 40.00 Change of Therapy Assessments 60 6.9% 19.90 34.00 40.00 Ultra High RUG Days 3,097 58.5% 64.60 71.40 69.30 Therapy RUG Days 5,292 72.8% 8.80 13.70 15.00 90+ Day Episode of Care 19 9.0% 25.90 36.90 32.90 ≥ 80th Percentile ≤ 20th Percentile Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 30
  31. 31. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Therapy RUG Days Ultra High RUG Days Therapy High ADL Days Non-Therapy High ADL Days 90+ Day Episode of Care Change of Therapy Assessments Percent Target Areas National Comparative Data (Actual Percentages) 80th Percentile Actual SNF 20th Percentile HHI Comparative Data Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 31
  32. 32. Actual SNF 20th Percentile 50th Percentile 80th Percentile 72.8% 85.5% 93.2% 97.3% 58.5% 28.1% 53.9% 73.1% 51.6% 20.0% 32.9% 48.1% 26.7% 11.5% 23.4% 42.2% 9.0% 7.5% 14.1% 25.9% 6.9% 7.0% 12.7% 19.0% Non-Therapy High ADL Days 90+ Day Episode of Care Change of Therapy Assessments Target Area Therapy RUG Days Ultra High RUG Days Therapy High ADL Days National Comparative Data-Actual Percentages HHI Comparative Data Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 32
  33. 33. Concluding Thoughts on PEPPER There is no “Good” or “Bad” PEPPER Compliance chart auditing at regular intervals for outlier areas Analyze PEPPER data Develop a Compliance Program Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 33
  34. 34. Concluding Thoughts on PEPPER PEPPER is a Tool for Ensuring Compliance with High Risk Areas Accurate and Appropriate Reimbursement for Care Provided Compliance is the Foundation for Accurate and Appropriate Reimbursement Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 34
  35. 35. Identify areas of exposure Identify areas of strength Highlight weak areas and prioritize solutions Seek interdisciplinary participation Harmony Healthcare International, Inc. Conduct Baseline Audits Copyright © 2014 All Rights Reserved 35
  36. 36. Introduction to Healthcare Compliance for the SNF Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 36
  37. 37. In 2012, the government received the highest amount of whistleblower complaints in its history This, combined with the advent of the Affordable Care Act and PEPPER, leaves the entire SNF industry under overwhelming scrutiny for accurate payment Numerous changes taking place specifically within the reimbursement process Medicare and Medicaid billing are now the most prominent risk areas in healthcare Harmony Healthcare International, Inc. Compliance Programs Copyright © 2014 All Rights Reserved 37
  38. 38. Critical changes have occurred with the False Claims Act Most noteworthy change; Leaders be advised! Revision of the "intent" to submit an incorrect claim Harmony Healthcare International, Inc. Compliance Programs Copyright © 2014 All Rights Reserved 38
  39. 39. Historically, proof of "intent" was required to prosecute Today, no proof or specific intent to defraud is required Harmony Healthcare International, Inc. Compliance Programs Copyright © 2014 All Rights Reserved 39
  40. 40. The government only needs to show: 1. The provider had "actual knowledge of the information" or 2. The person acted in "deliberate ignorance" of the truth or the falsity of the information, or 3. The person or provider acted in "reckless disregard" of the truth or falsity of the information Harmony Healthcare International, Inc. Compliance Programs Copyright © 2014 All Rights Reserved 40
  41. 41. Providers have only 120 days to correct MDS errors and submit a billing adjustment for Medicare Part A claims Late identification of billing errors yields mandatory self disclosure within 60 days of overpayment identification It is a felony not to return the payment The civil penalty for the aforementioned is $5,500 to $11,500 per false claim along with three times the amount of damages which the government sustained Harmony Healthcare International, Inc. Compliance Programs Copyright © 2014 All Rights Reserved 41
  42. 42. The only defense for an incorrect claim is a great offense in the form of an effective Compliance Program Harmony Healthcare International, Inc. Compliance Programs Copyright © 2014 All Rights Reserved 42
  43. 43. The following 7 elements are outlined for your success: 1. Written Policies and Procedures 2. Compliance Officer, Committee and Oversight 3. Effective Training and Education 4. Effective Lines of Communication 5. Transparent Disciplinary Standards 6. Effective Auditing and Monitoring 7. Prompt Response to Compliance Issues Harmony Healthcare International, Inc. Compliance Programs Copyright © 2014 All Rights Reserved 43
  44. 44. Compliance Programs The Office of Inspector General encourages SNFs to develop and implement a compliance program to protect their operations from fraud and abuse Beginning in 2013, SNFs are required to have a compliance program As part of a compliance program, a SNF should conduct regular audits to ensure services provided are necessary and that charges for Medicare services are correctly documented and billed Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 44
  45. 45. Compliance Programs Beginning March 2013, SNFs are required to have a compliance program OIG has determined seven elements that are fundamental to an effective compliance program Principles that each nursing facility should consider when developing and implementing an effective compliance program May require a significant commitment of time and resources by all parts of the organization Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 45
  46. 46. Compliance Programs “Superficial efforts or programs that are hastily constructed and implemented without a long term commitment to a culture of compliance likely will be ineffective and may expose the nursing facility to greater liability than if it had no program at all” Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 46
  47. 47. Cost of Compliance Program An effective compliance program may require a reallocation of existing resources The long term benefits of establishing a compliance program significantly outweigh the initial costs Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 47
  48. 48. Cost of Non-Compliance $305,072 was required to hire a full-time physician or NP after it was found to have sub-standard pressure ulcer treatment and prevention, incontinence care, pain management, nutrition, weight monitoring, infection control, and diabetic care Criminal sanctions may be mitigated by an effective compliance program $1.5 Million for submitting claims to Medicare and Medicaid for services provided by an unlicensed speech therapist $13 Million Dollars for incentives for productivity and providing care not supported by documentation Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 48
  49. 49. Benefits of Compliance Formulation of effective internal controls to ensure compliance with statutes, regulations and rules Demonstration to employees and the community of the commitment to responsible corporate conduct Obtain an accurate assessment of employee and contractor behavior Identifying and preventing unlawful and unethical behavior Prompt reaction to employees’ operational compliance concerns and effectively target resources to address those concerns Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 49
  50. 50. Benefits of Compliance Improvement in the quality, efficiency, and consistency of providing services Establish a mechanism to encourage employees to report potential problems and allow for appropriate internal inquiry and corrective action Centralized source for distributing information on health care statutes, regulations and other program directives Improve internal communications Prompt and thorough investigation of alleged misconduct Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 50
  51. 51. Benefits of Compliance Early detection and reporting, minimizing loss to the Government from false claims, and thereby reducing the nursing facility’s exposure to civil damages and penalties, criminal sanctions, and administrative remedies Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 51
  52. 52. Seven Elements of Compliance Policies and Procedures Reporting and Investigating Education and Training Prevention and Response Auditing and Monitoring Responsibility/Oversight of Compliance Officer/Committee Enforcement, Discipline and Incentives Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 52 P-R-E-P-A-R-E
  53. 53. Creating and Enforcing Policies and Procedures Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 53 Compliance Programs
  54. 54. Policies and Procedures The development and distribution of written standards of conduct Policies, procedures and protocols that promote the SNFs commitment to compliance Includes policies for adherence to the compliance program Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 54
  55. 55. Policies and Procedures Set expectations in easily read language Living documents that do not collect dust on the shelf Functional for the Organization Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 55
  56. 56. Policies and Procedures Policy: Statement of Approach Procedures: Steps to Achieve The development and distribution of written standards of conduct Policies, procedures and protocols that promote the SNF’s commitment to compliance Includes adherence to the compliance program Clear Language Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 56
  57. 57. Policies and Procedures Code of Conduct Provides expectations Practical Guidance Accountability Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 57
  58. 58. Policies and Procedures Best practice & policy and procedure for: MDS Completion MDS Accuracy ADL Accuracy Nursing Documentation Billing Triple Check Therapy Documentation completion Therapy Billing Logs Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 58
  59. 59. Compliance Officer and The Board Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 59 Compliance Programs
  60. 60. Program Oversight Choosing the Right Compliance Officer High Level Executive, credible, integrity Authority and resources to get the job done Who does the Compliance Officer report to? Knowledgeable Board No barrier to access Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 60
  61. 61. Program Oversight Oversight of Compliance Officer/Committee “charged with the responsibility for developing, operating and monitoring the compliance program, and who reports directly to the owner(s), governing body and/or CEO” Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 61
  62. 62. Program Oversight Communicate High Risk Areas to Staff Employees Contract Providers Communicate Plan to ensure compliance Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 62
  63. 63. Education and Training Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 63
  64. 64. Education and Training #1 Reason for Non-compliance is lack of training Facility Compliance process Risk Areas identified by Risk Assessment Focused Mandatory – Reinforced regularly Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 64
  65. 65. Education and Training Easy to understand focused education Risk Areas ADL Documentation Therapy Documentation Therapy Minutes Accuracy Nursing Documentation MDS Accuracy Billing Accuracy Compliance with technical and clinical Medicare requirements Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 65
  66. 66. Education and Training The goal is to yield change in behavior Employees to make the right choices Practical and effective training programs Make education diverse and not routine Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 66
  67. 67. Education and Training Internal Controls Preventative Detective Directive Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 67
  68. 68. Education and Training “The development and implementation of regular, effective education and training programs.” Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 68
  69. 69. Communication Reporting and Investigating Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 69 Compliance Programs
  70. 70. Communication Establish a code of conduct prioritizing compliance OIG requires “effective line of communication between the compliance officer and all employees, including a process, such as a hotline or other reporting system, to receive complaints, and the adoption of procedures to protect the anonymity of complainants and to protect whistle blowers from retaliation” Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 70
  71. 71. Communication Employees and Stakeholders require an anonymous system to seek guidance and report violations Hot line Log all calls Non-retaliatory Trusting atmosphere so staff feels safe to disclose Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 71
  72. 72. Communication Fact finding before full investigation May require a management solution vs. an investigation Once identified, resolution may be easily obtained Investigation warranted Consistency defined by high level officers prior to initiation Investigators require expertise How will the findings be documented Is Attorney Client privilege required (This should not be routine in nature – could be challenged) Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 72
  73. 73. Reporting and Investigating Includes an Anonymous System Non-Retaliation Philosophy to report concerns Investigate all concerns Investigator/Auditor should have a specialty in subject matter Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 73
  74. 74. Identification of Non-Compliance Respond MDS Corrections within 120 Days of Billed Date Billing Adjustments Staff Concerns Investigate all reports of non-compliance Report Seek Counsel to determine requirements Enforcement and Discipline Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 74
  75. 75. Enforcement, Discipline and Incentives Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 75 Compliance Programs
  76. 76. Enforcement and Discipline Employees must abide by: The law Code of Conduct Compliance Program stipulations Employees have a duty to report suspected misconduct Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 76
  77. 77. Enforcement and Discipline Investigate promptly and thoroughly Professionalism Consistency with discipline Reflect the severity of the violation Compliance officer and management are accountable Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 77
  78. 78. Enforcement and Discipline Define disciplinary standards for the organization Document all disciplinary actions taken Evaluation of job performance should include criteria for non-compliance Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 78
  79. 79. Incentives Ethical incentives consistent with the organization’s compliance program Creative incentives Often cash and cash equivalents are not allowed Verbal feedback from supervisor Public recognition What is the message the organization is sending? Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 79
  80. 80. Enforcement, Discipline and Incentives Follow Policies Consistent Discipline Incentives to be Compliant Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 80
  81. 81. Auditing and Monitoring Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 81 Compliance Programs
  82. 82. Focus on Compliance Auditing and Monitoring “The use of audits and/or other risk evaluation techniques to monitor compliance, identify problem areas, and assist in the reduction of identified problems” Detect Prevent Deter Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 82
  83. 83. Auditing and Monitoring Monitoring Common management tool Determines how effective the controls are Know what is happening in the field Day to day reviews Includes self reviews and peer reviews Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 83
  84. 84. Auditing and Monitoring Auditing Completed by someone with no vested interest The higher the level of independence an auditor has in relation to an organization, the greater the integrity of the audit Risk Adjusted Selection Formalized Approach Established Approach Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 84
  85. 85. Auditing and Monitoring Auditing Internal audit is NOT the control Internal audit tests and evaluates the controls Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 85
  86. 86. Auditing and Monitoring As part of a compliance program, a SNF should conduct regular audits to ensure services provided are necessary and that charges for Medicare services are correctly documented and billed Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 86
  87. 87. Auditing and Monitoring Monitoring Common Management tool Determines how effective the controls are Helps facility or corporate know what is happening in the field Day to day reviews Includes self reviews and peer reviews Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 87
  88. 88. Auditing and Monitoring Auditing Completed by someone with no vested interest Formalized Approach Established approach Methodology Effectiveness of correction Scientific sampling when completing for corrective plan Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 88
  89. 89. Response and Prevention Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 89 Compliance Programs
  90. 90. Response and Prevention Respond to reports Root cause analysis Provide education in risk areas Develop policy and procedure to prevent non-compliance Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 90
  91. 91. Enforcement and Discipline Investigate promptly and thoroughly Professionalism Consistency with discipline Root Cause Analysis to resolve the problem Compliance officer and management are accountable Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 91
  92. 92. Risk Assessment Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 92 Compliance Programs
  93. 93. Risk Assessment Identify Measure Prioritize Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 93
  94. 94. High 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 Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 94
  95. 95. Risk Assessment Determine risk areas Prioritize on severity, likelihood and impact Ongoing assessment Best Practice Changes in Policy Medicare MDS Therapy Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 95
  96. 96. Secrets to Success Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 96 Compliance Programs
  97. 97. Appoint Compliance Officer/Committee High level executive to oversee compliance program Reports directly to the top Authority and Resources to complete job Credible Demonstrates integrity Prioritizes Manages versus completes tasks Makes it real Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 97
  98. 98. Communication Introduce Compliance Officer Present Code of Conduct Educate staff on Compliance Program Development and Plan Initiate a process for reporting Anonymous Initiate a process for investigating all reports Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 98
  99. 99. Complete a Risk Assessment Determine Risk areas Develop an Annual Plan You Can’t Do It All Prioritize Prioritize on severity Facility specific history Established CIA Agreements Denials Known Deficiencies Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 99
  100. 100. Complete a Risk Assessment Prioritize likelihood Staff Turnover in Key Roles Changes in Federal/State Policy OIG Reports PEPPER Prioritize impact Volume Fines and Penalties Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 100
  101. 101. Pick a Starting Point Program for Evaluating Payment Patterns Electronic Report (PEPPER) Therapy RUGs with High ADLs Non-therapy RUGs with High ADLs Change of Therapy Assessment Ultra High RUGs Therapy RUGs 90+ Day Episodes of Care Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 101
  102. 102. Analyze and Plan Identify a point staff member for identified risk area Policy and Procedure Review Update/Create Education Plan Current Staff On Hire Annually/Quarterly Formal/Informal Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 102
  103. 103. Enforcement, Discipline and Incentives Consistent Enforcement Role Model Prompt Discipline Human Resources involvement Advice of Counsel Positive reinforcement and incentives for compliance Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 103
  104. 104. Keys to Success Provide clinically appropriate care Document Medical necessity Deficits Outcomes Meet technical requirements Review entire medical record Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 104
  105. 105. Bibliography Office of Inspector General, U.S. Department of Health and Human Services (OIG) “Inappropriate Payments to Skilled Nursing Facilities cost Medicare more than a Billion Dollars in 2009” (November 2012) OIG “Questionable Billing by Skilled Nursing Facilities” (December 2010). PEPPERResources.org PEPPER HELP Desk: (http://pepperresources.org/HelpContactUs.aspx) Skilled Nursing Facility Users Guide http://pepperresources.org/LinkClick.aspx?fileticket=xnGEABk7_d U%3d&tabid=172 UB04 claim form Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 105
  106. 106. Harmony Healthcare International (HHI) For attending this seminar, you are eligible for one of the following: Free PEPPER Analysis Free RUGS Analysis Assess your facility against key indicators and national norms. Contact us at: RUGS@harmony-healthcare.com Analysis is cost & obligation free Harmony Healthcare International, Inc. 106Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  107. 107. Questions/Answers Harmony Healthcare International (978) 887 - 8919 www.Harmony-Healthcare.com Connect with Us! @elisabovee @Harmonyhlthcare facebook.com/HarmonyHealthcareInternational H linkedin.com/company/harmony-healthcare Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 107
  108. 108. Upcoming Seminars & Webinars Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. A Hands on Approach on How to Respond to ADR’s & Appeals in the SNF August 4, 2014: 8:30am-3:30pm Harmony University, Topsfield, MA Speaker: Carrie Mullin, OTR/L, RAC-CT, Claims Review Specialist 108 Online Registration Coming Soon! http://www.harmony-healthcare.com/education- training/schedule/ Visit our website for webinars, seminars & workshops!
  109. 109. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 109 Register online http://info.harmony-healthcare.com/harmony2014 or by phone (978) 887-8919 ext. 13 Register Online
  110. 110. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 110

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