HEALTHCARE COMPLIANCE 2 – Discussion (HOME CARE) Among the biggest changes to home care in 2018: the fact that federal policymakers will allow some non-ski

HEALTHCARE COMPLIANCE 2 – Discussion (HOME CARE) Among the biggest changes to home care in 2018: the fact that federal policymakers will allow some non-ski

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Among the biggest changes to home care in 2018: the fact that federal policymakers will allow some non-skilled in-home care services under the Medicare Advantage (MA) program starting next year.

What are you thoughts of these new changes?

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Chapter 18

Hospices and Home Health Agencies

Learning Objectives

Contrasts between hospices & home health agencies

Common fraud types in these entities

Benefits of an effective compliance program

Implementing a 7-element compliance program

Purpose of a Code of Conduct

Risk areas unique to hospices & home health agencies

Fraud between hospices and nursing homes


“Home care organizations” include home health care agencies, home care aide organizations, and hospices.

The two types of these entities that have received the most attention from the OIG are hospices and home health agencies.

The Hospice Care Industry

The Home Health Industry

The Hospice Care Industry (I)

Hospices provide expert medical care, pain management, and emotional and spiritual support tailored to the needs of terminally ill patients.

A hospice focuses on caring, not curing.

In 2011, approximately 1.65 million patients received services from a hospice.

The Hospice Care Industry (II)

Of these, one million patients died under hospice care, 300,000 were discharged alive, and another 300,000 remained under hospice care.

The Hospice Care Industry (III)

In 2010, Medicare expenditures on hospice care totaled about $13 billion.

They were the major (84%) source of payment for hospice care.

Four general levels of hospice care:

Level 1. Routine Home Care

Level 2. Continuous Home Care

Level 3. General Inpatient Care

Level 4. Inpatient Respite Care

The Home Health Care Industry

Home health care allows homebound individuals to stay in their homes by providing medical equipment and services to them in their homes.

Medicare pays for skilled nursing services, home health aide services, physical and occupational therapy, speech-language pathology, medical social services, medical supplies other than drugs and biologicals, and durable medical equipment.

In 2011, about 3.4 million Medicare beneficiaries received home health services from 11,633 HHAs.

OIG Guidance for Compliance Programs

OIG standard structure for a compliance program

Standards, Policies, and Procedures

Compliance Officer and Committee

Training and Education

Reporting and Investigating

Enforcement and Discipline

Monitoring and Auditing

Response and Prevention

Benefits of an Effective
Compliance Program

Demonstrate commitment to responsible provider and corporate conduct

Identify and prevent illegal & unethical conduct

Improve quality & consistency of patient care

Enable employees to report potential problems

Facilitate investigation of alleged misconduct

Initiate immediate & appropriate corrective action

Minimize exposure to civil & criminal legal penalties

Standards, Policies, and Procedures

Code of Conduct – broad guidelines for employees, managers, contractors, vendors, and clinicians in the performance of their jobs

Policies & procedures – prescribe in detail how specific tasks in high compliance-risk areas are to be carried out

Compliance Risk Areas Unique to Home Health Agencies

31 areas in HHA program guidance

Claim Development and Submission

Medical necessity, homebound beneficiaries, physician certification of plan of care, cost reports

Anti-Kickback and Physician Self-Referral laws


Compliance Risk Areas Unique to Hospices

28 areas in hospice program guidance

Eligibility Requirements

Terminal illness as an eligibility requirement, plan of care, levels of hospice care

Hospice Arrangements With Nursing Homes

Other Elements of a Compliance Program for HHA’s and Hospices

Compliance – a factor in performance appraisals

Establishment of a compliance infrastructure: Compliance Officer and Compliance Committee

Compliance training and education

Lines of communication for complaints/reports

Disciplinary action for non-compliance

Auditing and monitoring compliance efforts

Responding to and correcting non-compliance


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