3 reasons to schedule a compliance assessment

From an OIG directive to the labor shortage, there are compelling reasons to let SimiTree assess your risk. 

The public health emergency remains in effect at least through July, but Medicare is beginning to increase its scrutiny on providers after two years of limited reprieve during the COVID-19 pandemic.

Program integrity audits are on the increase, with Medicare contractors searching out providers who took advantage of the pandemic to step outside the rules, cheat the system, or pad their pockets.

And it’s not just the unscrupulous who are feeling Medicare’s renewed zeal.

Almost all home health and hospice providers will feel the impact as audits increase, investigations toughen and Medicare oversight shifts into normal mode after some degree of leniency during the pandemic years.

More audits, more inspections

SimiTree compliance experts say audits and investigations are intensifying at the direction of the Office of Inspector General (OIG), the federal agency in charge of investigating fraud and abuse.

“In its most recent biannual work plan, the OIG recommended more investigation, auditing and inspection of all healthcare providers,” said Kim Skehan, SimiTree Director of Compliance, Regulatory and Quality.

“While the OIG may directly conduct investigations, these OIG audit directives are also performed by the Centers for Medicare and Medicare Services, Medicare program integrity contractors and the state agencies that are responsible for conducting investigations.” Skehan said. “As a result, when the OIG calls for more audits and investigations, that’s exactly what happens.”

TPE, RAC, UPIC audits

Recent audit activity indicates the OIG directive is being taken seriously by home health and hospice auditors.

Medicare audits by contractors ramped up in the spring with a flurry of new Target, Probe and Educate (TPE) audits, generally considered the “friendliest” of the Medicare audits because the audit process is more educational than punitive. The audit includes coaching for the provider to correct the erroneous billing or documentation practices that caused the audit.

“However, failure to meet the TPE threshold for compliance will result not only in denial of payment, but advancement to Round 2 or 3 TPE, and potentially 100% pre-payment review by the Medicare contractor if satisfactory improvement in thresholds is not met,” Skehan said.

In addition to TPE, many agencies have also received audit letters, record requests or site visits from Recovery Audit Contractors (RAC), Supplemental Medical Review Contractors (SMRC) or Unified Program Integrity Contractors (UPIC), which may be considered much more serious. RAC, SMRC or UPIC auditors are less interested in education than in collecting overpayment associated with improper coding or billing. They may also pursue adverse administration actions such as termination, suspension or revocation of billing privileges and extrapolation of denied payments.

A best-case scenario may be a focused review and additional documentation requirements for the provider for all episodes going forward. In a worst-case scenario, auditors may refer the provider to law enforcement for action.

The federal Health Care Fraud Prevention & Enforcement Action Team (HEAT) is a special task force created in response to the rise of Medicare and Medicaid fraud and abuse. It is comprised of law enforcement from the U.S. Department of Justice (DOJ) and professional investigators from the Department of Health and Human Services (HHS).

“It’s important to note that a provider being audited may have done nothing wrong,” Skehan said. “And most of the providers audited aren’t perpetrating intentional fraud. They’re making mistakes. But it can be a harrowing, time-consuming and costly experience to go through an audit, all the same.”

A compliance assessment finds vulnerabilities

The best safeguard is a well-trained staff, operating with the regulatory knowledge to meet requirements and avoid billing errors and insufficient documentation that flag providers for audit.

SimiTree’s compliance experts offer a full compliance assessment to identify risks so providers can correct clinical, quality and billing vulnerabilities and provide any needed training to their teams to shore up compliance.

“There has probably never been a better time for a full compliance assessment than right now, in light of the OIG directive and numerous other signs that Medicare is looking more carefully at providers,” Skehan said.

Each hospice compliance assessment by SimiTree carefully examines billing practices and ensures that medical records are meeting clinical requirements for medical necessity and Medicare eligibility.

“We look for the same things auditors will look for,” Skehan said. “Examples are insufficient documentation, missing orders, problems with patient plans of care, services billed in excess of ordered hours, and other issues that place providers at compliance risk.”

SimiTree’s hospice compliance assessment includes corrective plan recommendations, with additional compliance and regulatory implementation support, Skehan added.

Staffing shortage may increase risks

The OIG directive isn’t the only reason Skehan is encouraging organizations to schedule full compliance assessments. Many agencies have seen numerous staffing shifts during the ongoing labor shortage, opening a new window of vulnerability.

“Knowledge deficits and misunderstandings about regulatory requirements tend to occur with greater frequency during times of turnover,” she said. “When key leadership positions go unfilled, the organization may not have the knowledgeable oversight in place to make sure all regulations are being followed.”

The staffing shortage may also place agencies at risk for investigations due to complaints made by patients, their representatives, or their families, Skehan said.

“If being shorthanded creates a scheduling problem that delays a visit, or if the agency is unable to get an aide to see the patient, the patient or the patient’s family may file a complaint, triggering an investigation,” Skehan said.

Compliance and future possibilities

While there are plenty of reasons in the here-and-now to try to avoid audits, an organization’s future may hinge on how well it controls compliance risk.

“Investors look for a strong track record on regulatory compliance when selecting acquisition targets.” Skehan said. “Even if you’re not ready to sell right now, it’s a good idea to shore up any risks and polish your organization’s compliance in preparation for any future partnerships or acquisitions.”

SimiTree can help

SimiTree compliance experts have the experience to help your organization navigate the audit and appeal process. Our team is made up of clinical experts who are certified in healthcare compliance with extensive experience in government audits and appeals at all levels, including ALJ expert witness. In addition, current, former and certified surveyors provide best-in-the-industry comprehensive compliance and regulatory support to meet an organization’s needs.

“However, we recommend that you enact preventative measures to reduce the risk of audit before the audit notification arrives,” Skehan said. “We can help with staff training needed to avoid billing and documentation errors and omissions that generate audits.”

SimiTree’s full compliance assessments will identify exactly where those risks are occurring, targeting where training is needed. Our corrective action plan will explain exactly how to address any risks and vulnerabilities identified in the assessment.

Use the form below to reach out to us to begin the conversation about shoring up your compliance.

Contact Us

Let's work together to improve the health of your organization. At SimiTree, we balance financial expertise and clinical excellence to help our clients grow. How can we help you? Call us at 800.949.0388 or complete the form below.