07.25.2022

Creating an Effective Compliance Program

How effective is your compliance program?

With audits for home health and hospice on the rise, focus on these compliance priorities

Has your organization been targeted for a payment-related Medicare audit?

Medicare contractors are ramping up the number of audits targeting home health and hospice providers, following a recent directive from the Office of Inspector General (OIG), the federal agency in charge of investigating fraud and abuse.

In its most recent work plan, the OIG called for more investigation, auditing and inspection of all healthcare providers.

“We’re already seeing more activity by Medicare audit, medical review and program integrity contractors,” said Kim Skehan, SimiTree Director of Compliance, Regulatory and Quality. “And we expect to continue seeing higher numbers of audits in response to the OIG directive.”

Skehan recommends home health and hospice providers respond to increasing Medicare scrutiny by prioritizing compliance, focusing on both internal and external evaluation. She said agencies should also provide staff training to shore up areas of weakness and consider outsourcing billing and other revenue cycle services to better insulate themselves against audits.

“Payment-related audits are triggered by both aberrant billing practices and government data analytics,” Skehan said. “To insulate themselves, agencies need to identify and correct any aberrant processes and use data analytics to understand the patterns leading to audits.”

Priorities for agencies

Skehan recommends the following priorities for agencies in response to increasing payment-related audits.

  1. Use the OIG compliance program blueprint. Start by making certain your organization has in place a solid compliance program that incorporates each of seven fundamental elements of compliance set out by the OIG. See Seven Fundamental Elements of an Effective Compliance Program, outlined below.
  2. Use data to identify patterns triggering scrutiny. Medicare’s Program for Evaluating Payment Patterns Electronic Report (PEPPER) and other EMR reports provide dashboard measures, patterns and percentages revealing how and where an agency may deviate from state or national averages. Monitor these reports regularly, and check for updates on CMS, OIG and DOJ websites, to stay abreast of areas of audit focus.
  3. Set up internal monitoring programs. Skehan recommends developing quarterly and annual audit plans for oversight, focusing on identified problem areas. “Self-monitoring reduces the likelihood of abusive or reckless habits and potential overpayments,” she said.
  4. Consider external evaluation as well. Skehan recommends using objective external auditors for quarterly or annual audit and education. SimiTree offers services ranging from prebill audits to full compliance assessment. Each 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.”
  5. Provide targeted and ongoing education. In the same way HIPAA education is required to be repeated and updated, training for proper clinical documentation and requisite billing practices should be provided frequently. A solid compliance program will also educate staff about the harm and potential criminal penalties associated with payments for referrals.
  6. Consider outsourcing billing services or full revenue cycle management. Staffing shortages and turnover pose additional compliance risks to organizations already under pressure to maintain billing staff with regulatory knowledge. Outsourcing can be the solution. SimiTree’s revenue cycle expertise is fully supported by our compliance and regulatory experts.

What makes a solid compliance program?

The OIG sets out Seven Fundamental Elements of an Effective Compliance Program to guide providers in implementing effective compliance efforts.

Skehan said having these fundamental elements of compliance in place will help agencies with all aspects of compliance, including HIPAA and Medicare Conditions of Participation (CoP) compliance as well as payment-related compliance issues.

The OIG recommends:

  • Implement written policies, procedures and standards of conduct.
  • Designate a compliance officer with the education needed to implement and enforce policies. Establish a compliance committee as well. Multi-location providers will need leaders at both the corporate and agency level in designated roles.
  • Conduct effective training and education.
  • Develop effective lines of communication and reporting, including establishment of anonymous reporting processes.
  • Conduct internal monitoring and auditing. In addition to quarterly or annual audits for payment-related issues, SimiTree compliance experts recommend agencies conduct mock surveys at least annually to evaluate compliance with CoP. Ensure ongoing review and observation to ensure staff knowledge of policies and procedures.
  • Enforce standards through well publicized disciplinary guidelines.
  • Respond promptly to detected offenses and undertake corrective action.

SimiTree can help

SimiTree compliance and regulatory experts provide comprehensive compliance and regulatory support to meet all an organization’s needs.

We offer prebill audits, full compliance assessments, mock surveys, and other compliance assessments designed to evaluate your compliance risk. We can also help agencies 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.

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

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