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Posts Tagged ‘hospice’

Fraud Risks In Nursing Home/Hospice Relationships

Wednesday, October 30th, 2013

Fraud Risks Between Nursing Homes and Hospice Providers

Hospice Nursing Home Fraud and AbuseRelationships between hospices and nursing homes are a particular area of concern.  OIG is inherently suspicious of benefits that hospices may provide to nursing homes in order to gain hospice referrals of nursing home patients.  For example, if a hospice provides services to nursing home patients that are normally provided by the nursing home, the benefit could be deemed to be a “kickback” for referrals.  Hospices should have clear policies and procedures regarding the scope of services to be provided to nursing home patients.  Any formal agreement with a nursing home should be carefully scrutinized to assure compliance and provision should be added agreeing to the appropriate scope of care that is to be provided to nursing home patients.

Government focus on hospice providers should heighten awareness to these issues.  Hospices must make certain that they have formal compliance programs in place and that the compliance program is actively operated to identify and address risk.  Certainly, the risks identified above should be addressed by all hospice providers.  There are a broad range of additional items that should be actively addressed.  Additionally, all elements of the compliance program should be fully operationalized.  Even the most robust compliance program will not necessarily detect all compliance problems.  It is important that hospice providers are able to demonstrate that they are continually monitoring risk and operating their program.  When undetected programs come to light, the hospice provider will be able to show that reasonable steps are routinely taken to identify and correct problems.  This will go a long ways toward reducing potential exposure, even in cases where risk is not detected through the program.

Hospice and Home Health Areas of Review Risk

Wednesday, September 18th, 2013

Home Health and Hospice Review Areas

home health hospice fraud reviewsThere are several areas applicable to home health and hospice that are susceptible to review.  Hospice reviews have tended to focus on whether patients actual meet criteria to be eligible to receive hospice benefits.  The focus on hospice arises, at least in part, due to the expansion of this segment of health care industry and the relatively rapid increase in spending for hospice care.  The government’s audit and enforcement trends indicate a deep suspicion that hospice are admitting patients who are not terminal or do not otherwise meet eligibility criteria.  The government points to the relatively large number of hospice patients who are discharged from hospice care alive.

In order to qualify for hospice benefits, a Medicare patient must have an illness that is terminal.  A physician must certify that the patient is terminal and is unlikely to live longer than six months if the illness runs its expected course.  The patient must also waive their right to receive curative treatment for the terminal condition in order to qualify for benefits.  Physician certification must be provided at two 90-day intervals following hospice admission.  After the first 180 days of hospice care, the patient must be seen “face-to-face” by a nurse practitioner who determines continued eligibility for coverage.  This process of certification and admission qualification creates several obvious pouts of risk for providers.  The government seems to be keying in on a few of these points of risk as evidenced by recent enforcement actions.

Payments to physicians for administrative duties should be carefully scrutinized to assure that the compensation arrangement does not create a referral inducement.  Medical director agreements must be analyzed under the Anti-Kickback Statute and applicable Stark Law exceptions.  Compensation should be at fair market value, cannot take into account he volume or value of referrals, and must meet other regulatory requirements.

Home Health Hospice Face-to-Face Certification Rule

Thursday, April 7th, 2011

CMS Begins Enforcing Home Health and Hospice Face To Face Rule

On March 31, 2011, the Center for Medicare and Medicaid Services issued a statement that it intends to begin enforcing the home health and hospice “face-to-face” requirement.  The Accountable care Act established a face-to-face encounter requirement before eligibility for Medicare home health services can be certified.  A certifying physician is now required to document that the physician or a non-physician practitioner that works with the physician has seen the physician “face-to-face.”  Face-to-face encounters with hospice patients must also occur  prior to the patient’s 180th-day re-certification, and each subsequent re-certification.

 The face-to-face requirement went into effect on January 1,  2011 but CMS announced in December 2010 that it would suspend enforcement for the first calendar quarter of 2011 in order to give providers additional time to establish compliance protocols.  CMS has stated that it expects providers (home health and hospices) to have fully established and implemented internal processes to be in compliance with the face-to-face requirement and by April 1, 2011, Home health providers and physicians are required to ensure that a face-to-face encounter with a home health or hospice patient occurs within the 90 days prior to the start of care, or within the 30 days after the start of care in order to appropriately certify the need for home health services.  Documentation of the face-to-face requirement must be included with patient certifications.

John H. Fisher

Health Care Counsel
Ruder Ware, L.L.S.C.
500 First Street, Suite 8000
P.O. Box 8050
Wausau, WI 54402-8050

Tel 715.845.4336
Fax 715.845.2718

Ruder Ware is a member of Meritas Law Firms Worldwide

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