Author Archives: Kate Frech

Guidance Released for Health Care Governing Boards

On April 20, 2015, the Office of Inspector General (the “OIG”) of the U.S. Department of Health and Human Services, the Association of Healthcare Internal Auditors, the American Health Lawyers Association, and the Health Care Compliance Association published a first-of-its-kind guide entitled “Practical Guidance for Health Care Governing Boards on Compliance Oversight.”

The guide is intended to assist governing boards of health care organizations (“Boards”) to create and carry out compliance programs. The guide addresses issues relating to a Board’s oversight and review of compliance program functions, including: (1) the roles of, and relationships between, the organization’s audit, compliance, and legal functions; (2) the mechanism and process for issue-reporting within an organization; (3) the approach to identifying regulatory risks; and (4) methods of encouraging organization-wide accountability for achievement of compliance goals and objectives.

The guide encourages Boards to create benchmarks using publicly available resources, such as the Federal Sentencing Guidelines, the OIG’s voluntary compliance program guidance, and OIG Corporate Integrity Agreements.  Although there is no such thing as a “one size fits all” compliance program, these resources can be helpful in creating a program tailored to each organization’s needs.

While recognizing that not all organizations will possess the resources to support the structure in its entirety, the guide recommends creating corporate charters that address the following functions: (1) compliance; (2) legal; (3) internal audit; (4) human resources; and (5) quality improvement. Boards should continuously evaluate the effectiveness of these charters.

The guide also encourages Boards to ensure proper reporting mechanisms are in place within the organization. If managers or other individuals within the organization are not held responsible for reporting compliance concerns to the Board, the Board will not have a complete picture of the adequacy and effectiveness of the organization’s compliance atmosphere. Therefore, Boards should consider scheduling regular sessions to hear from the organization’s management about the organization’s utilization of compliance, legal, internal audit, and quality functions.

Identifying risk areas is an integral part of any organization’s compliance program. Boards can identify high risk areas from internal and external sources. The guide recommends tracking industry trends to identify risk areas, as new payment models can lead to new incentives and new compliance concerns.

Finally, the guide recommends encouraging accountability within an organization along with compliance. Many organizations have tied an employee’s performance assessment and other incentives to adherence to the organization’s compliance program to emphasize and encourage individual accountability.

The entire guide is available on the OIG’s website. For more information on health care compliance programs, please contact any member of Benesch’s health care practice group.

OIG Issues Report on Limited Compliance with Medicare’s Face-to-Face Requirement for Home Health Services

On April 9, 2014, the US Department of Health and Human Services Office of the Inspector General’s (OIG) Office of Evaluation and Inspections (OEI) issued a report (OEI-01-12-00390) entitled “Limited Compliance With Medicare’s Home Health Face to Face Documentation Requirements.”

The Center for Medicare and Medicaid Services (“CMS”) requires physicians to physically see and evaluate patients for home health services. The Patient Protection and Affordable Care Act requires the physicians to document this face-to-face visit as a condition of payment. The face-to-face requirement was implemented to help prevent fraud in home health. The idea is that requiring physicians to document the specifics of a face-to-face visit with a Medicare beneficiary will help prevent fraud by ensuring the physician actually saw and assessed the beneficiary before certifying the patient as eligible for home health services. Continue reading

CMS & OIG FINAL RULES EXTEND AND AMEND PROTECTION FOR EHR DONATIONS

Ordinarily, the donation of Electronic Health Record (EHR) technology, services or training to a provider would raise fraud and abuse concerns and potentially implicate the Stark law and Anti-kickback Statute. In order to encourage the use of EHR technology, in August of 2006, CMS and OIG published companion rules creating an exception to the Stark law and a safe harbor for the Anti-kickback Statute that protects arrangements involving the provision of EHR technology, services, and training to providers. The rules were scheduled to expire on December 31, 2013.
Continue reading

CMS Reports Hospital Readmission Rates Declining Under Affordable Care Act

A recent CMS news release reported that Affordable Care Act reforms are leading to lower hospital readmission rates for Medicare beneficiaries. Hospital readmission can be an indicator of poor care coordination or low-quality care. Readmission are also costly—CMS reports spending $17.8 billion a year on avoidable readmissions.
Continue reading

OIG Issues Updated Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs

On May 8, 2013, the Office of Inspector General (OIG) issued an updated Special Advisory Bulletin (Updated Bulletin) on the effects of exclusion from participation in Federal health care programs. The Updated Bulletin replaces the original bulletin on the topic issued in September 1999. The Updated Bulletin describes the scope and effect of the legal prohibition on submitting a claim or receiving a payment from a Federal health care program for items or services furnished: a) by an excluded person; or b) at the medical direction or prescription of an excluded person. An excluded person is a person whom the OIG has excluded from participation in Medicare, Medicaid, and other Federal health care programs after finding that the person has engaged in fraud, abuse, or other misconduct relating to Federal health care programs. Continue reading

CMS Proposed Rules for Immediate Jeopardy Situations for Providers Other than SNFs and NFs

In the April 5th Federal Register, the Center for Medicare and Medicaid Services (CMS) proposed new rules relating to immediate jeopardy situations for providers or suppliers that are not Skilled Nursing Facilities (SNFs) or Nursing Facilities (NFs). The proposed rules were published in April of 2013 in the Federal Register and generally apply to the oversight of accrediting organizations, but CMS also proposed a changed to the rule on providers and suppliers, other than SNFs and NFS, with deficiencies. Continue reading