These changes prompted the OIG to publish a notice in the Federal Register on January 24, seeking stakeholder comments,[3] and to publish this draft to seek comments from all interested parties. The OIG notes its particular interest in receiving comments regarding whether its original recommendations for the basic elements of compliance programs must be updated and, if so, how.
The draft guidance also contains an overview of Medicare and Medicaid reimbursement for nursing facilities, meant to serve as context for the discussion of fraud and abuse risk areas that the draft guidance provides.
The primary focus of the draft guidance addresses several areas of significant concern for nursing facilities today with regard to fraud and abuse: quality of care, submission of accurate claims, the federal anti-kickback statute, other risk areas, and HIPAA privacy and security rules. With regard to quality of care, the OIG provides guidance in several common risk areas associated with the delivery of quality care to nursing facility residents that frequently arise in enforcement cases, including sufficient staffing, comprehensive care plans, appropriate use of psychotropic medications, medication management, and resident safety.
With regard to claims, the draft guidance emphasizes the importance of properly reporting resident case-mix by SNFs as well as reporting risks that are unique to certain types of nursing facility services, including therapy, screening for excluded individuals and entities, and restorative and personal care services.
The draft guidance then discusses anti-kickback concerns that the OIG believes should receive close scrutiny from nursing facilities, such as the provision of free goods and services to existing or potential referral sources; services contracts for physician services and non-physician services; discounts in the form of price reductions and swapping; hospice services; and reserved bed arrangements.
Neither the beneficiary nor any person in lieu of the beneficiary e. However, a not-for-profit may solicit and accept donations unrelated to the care of a specific resident. The LTC facility guidance allows a great deal of latitude in design and operations, and a compliance program can and should be customized to fit the size, resources, and risks of the organization. There is plenty of work ahead for many facilities. Disclaimer : Legal advice should always be obtained from licensed and experienced legal counsel.
This case was a perfect storm of whistleblower litigation alleging poor quality care and fraudulent billing. The whistleblower sued under seal alleging care deficiencies and false billings.
After an investigation the federal government joined the case. Ciena Healthcare Management, Inc. The owner also owned Sunshine Therapy, providing physical and speech therapy. Relator Hubbard the original plaintiff alleged severe deficiencies in care with details by resident and also alleged cost report falsification. Billing fraud included therapy billings, fraudulent RUG reporting, Minimum Data Set MDS falsification, false certification, document destruction, back dating, kickback violations, and potential self-referral on a vendor account.
Apparently Ms. Hubbard had a brief and tumultuous employment with Ciena as an acting Director of Nursing at a Detroit area nursing facility, after which she retained counsel and took legal action. The CIA not only applied to all of the defendants but nearly anyone working, supplying, or contracting for Ciena for a period of five years.
It requires a thick blanket of obligations to be strictly monitored and enforced. A CIA is a tough, no-nonsense agreement placing stringent performance and reporting requirements on the provider. There are significant costs and the possibility of future penalties. Avoiding a CIA is one major reason to maintain a robust compliance program. Tom Ealey, MA, an associate professor of business administration at Alma College, has three decades of experience with long-term care as a CPA, consultant, seminar leader, and writer.
For more information, visit. Marcy Gilstad, a candidate for a Bachelor of Arts at Alma College, is a member of the Phi Beta Kappa scholars honorary and will attend graduate school studying healthcare administration. Sentencing Commission Guidelines for Organizations note the importance of organizations to develop institutional compliance cultures that discourage criminal conduct.
The OIG Compliance Program Guidance for Hospitals stresses similar points by stating that compliance efforts need to be designed to establish a culture that promotes prevention, detection, and resolution of instances of conduct that violate applicable laws, regulations, health care program requirements, and ethical business practices.
The OIG also calls for using benchmarks that demonstrate implementation and achievements as being essential to an effective compliance program. They further advise that consideration should be given to using questionnaires that solicit impressions of a broad cross-section of employees and staff.
This is only one of three methods the OIG notes for evidencing program effectiveness. In the Compliance Program Guidance for Nursing Facilities , the OIG recommends evaluations of compliance programs through the use of employee surveys , internal assessments, periodic review of benchmarks , and feedback from employees. They also note that it is important for a company to create and foster a culture of ethics and compliance with the law, and executive leadership needs to implement a culture of compliance from the top.
In the SAI Global and Strategic Management national Healthcare Compliance Benchmark Survey of compliance programs, respondents indicated that one-third of organizations use surveys on compliance issues with their work force, with most organizations relying upon internally generated and administered surveys. Since , Strategic Management has been employing a Healthcare Compliance Culture Benchmark Survey Survey on behalf of hundreds of health care organizations with a surveyed population of more than three quarters of a million.
This has created a huge database of users that permits organizations to benchmark their results against that universe. This can help ensure that the organization in on track towards creating a compliance culture of the highest quality.
It can provide great insights into how effective the compliance program has been in changing and improving the compliance of an organization and signal not only the strengths in the compliance program, but also the areas of potential weakness that may warrant attention. Employing this tool is surprisingly inexpensive and costs only a small fraction of a full compliance program effectiveness evaluation or even a gap analysis.
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