Friday, September 30, 2011

Daymarck Welcomes Carie Wright

We’re extremely pleased to introduce our new Director of Business Development, Carie Wright!

With more than 25 years of experience in the health care industry, Carie has fulfilled lead roles in data services and informatics sales, managed care formulary contracting, pharmaceutical sales, and consulting related to automated prescription tools. Carie holds a BBA in marketing from Stephen F. Austin University and is certified in Home Health and Managed Care Administration.

Here at Daymarck, she will be responsible for sales and account management. She will also participate in speaking at seminars, providing industry education, and cultivating strategic business opportunities.

If you’re heading to NAHC Annual, be sure to come by our booth (#862) to meet Carie!

Monday, September 26, 2011

NAHC Annual Meeting is Almost Here- Will you be there?

The clock is winding down, and the 2011 NAHC Annual Meeting is almost here! We’re looking forward to meeting all the home healthcare professionals in Las Vegas in just a few short days.
If you’re attending the show, we hope you will take a minute to stop by our booth (#862) and learn more about Daymarck’s Pain-Free answer to OASIS review and home healthcare coding. 
While you’re there, we also invite you to fill out our quick survey about converting to ICD-10. By participating, you will be eligible to win one of six casino-grade poker sets (a $150.00 value). Not attending? Don’t worry; you can fill out the survey now here.
You can also help us raise money for the Caring Institute by becoming a fan of Daymarck on either Facebook or Twitter by the end of the show. We’ll donate up to $1,000 to this deserving organization!
For those attending, we look forward to seeing you in Las Vegas! And if you can’t make it, stay tuned here and on Facebook or Twitter for updates during and post-show.

Thursday, September 22, 2011

Fraud and Abuse Compliance: A “Wake-Up Call” for Private Duty Providers

By: Elizabeth E. Hogue, Esq.

Agencies that provide private duty services only and Medicare-certified home health agencies that also provide private duty services may have erroneously concluded that the fraud and abuse prohibitions that apply to Medicare-certified agencies do not apply to private duty providers. Recent action against Maxim Healthcare makes it clear that this is not the case.  Maxim is a privately held company with 360 offices nationwide and approximately 88,000 staff members. While some of these locations are Medicare-certified, Maxim provides services primarily to Medicaid, including Medicaid waiver, patients. 

As a result of both criminal and civil investigations, Maxim has agreed to pay $150 million to the federal government and state Medicaid Programs to settle allegations of false claims.  Payments to the federal government include false claims made to the Veterans Administration.  In addition, nine employees of Maxim have already pled guilty to criminal charges; including three regional accounts managers, a Director of Clinical Services, a home health aide, an account manager, a recruiter, and a licensed practical nurse.  Action may yet be taken against other individual employees, including members of the upper management team.

Based on this case alone, it is clear that providers of private duty services are subject to the same fraud and abuse prohibitions as Medicare-certified agencies and must take action to help ensure compliance.  What kind of action should be taken by providers of private duty services? 

The statements of officials about the Maxim settlement offer clear direction.  New Jersey Attorney General Paula Dow, for example, said: “Companies like Maxim, that provide health care services to Medicaid patients, are expected to take necessary steps to prevent fraud and abuse by instituting strong compliance programs and maintaining effective internal controls.”

How do compliance programs, including effective internal control, help providers avoid enforcement action?  First, as a practical matter, when providers establish and maintain a Compliance Program, it clearly discourages regulators from pursuing allegations of fraud and abuse violations.  Technically speaking, the Federal Sentencing Guidelines make it clear that establishment and implementation of Compliance Programs is considered to be a mitigating factor.  That is, if accusations of criminal conduct are made, as they were in the Maxim case, the consequences may be substantially less severe as a result of a properly implemented Compliance Plan.

Providers with Compliance Plans are more likely to avoid fraud and abuse.  This is because Plans routinely establish an obligation on the part of each employee to prevent fraud and abuse and the Plans include training for all employees.  Compliance Plans make it clear that employees have an obligation to bring any potential fraud and abuse issues to the attention of their employers first.

Compliance Plans may help to prevent qui tam, or so-called “whistleblower” lawsuits by private individuals, rather than by government enforcers, who believe that they have identified instances of fraud and abuse.  There are significant incentives to bring these legal actions since “whistleblowers” receive a share of monies recovered as a result of their efforts.  Some whistleblowers have received millions of dollars.  The whistleblower in the Maxim case will receive over $15 million.

Finally, the Deficit Reduction Act (DRA) requires providers who receive more than $5 million in monies from the Medicaid Programs per year to implement policies and procedures, provide education to employees, and put information in their employee handbooks about fraud and abuse compliance.  These requirements can be met through implementation of a Fraud and Abuse Compliance Program.

In view of the above, all providers of private duty services should implement and maintain effective compliance plans.

In addition, as part of an agreement to defer prosecution, Maxim admitted in documents filed in court that “certain aspects of Maxim’s operations emphasized sales goals at the expense of clinical and compliance responsibilities, as reflected in certain aspects of its culture, training, incentive compensation and allocation of personnel resources.”  Based upon Maxim’s statement, providers of private duty services should review incentives in compensation to staff and should work to ensure that there are checks and balances on incentives that may encourage staff to engage in fraudulent conduct.  These measures should be built into agencies’ compliance plans.

It is quite clear that providers of private duty services must meet requirements regarding fraud and abuse compliance.  If they fail to do so, both criminal and civil enforcement action may be taken against them.

© 2011 Elizabeth E. Hogue, Esq. All rights reserved. 

No portion of this material may be reproduced in any form without the advance written permission of the author.

Thursday, September 15, 2011

New OIG Advisory Opinion on Provision of Items and Services Below Cost or Free of Charge to Referral Sources in Exchange for Referrals

In an Advisory Opinion posted on August 4, 2011, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services concluded that the provision of items and services below cost or free of charge to referral sources likely violates the federal anti-kickback statute.  A home medical equipment (HME) company requested the Advisory Opinion. 

The HME supplier provides medical supplies and equipment to skilled nursing facilities (SNF’s).  When the medical supplies and equipment that the HME company furnishes to SNF’s are covered by Medicare Part B, the HME company bills the Medicare Program for them.  When they are not covered under Medicare Part B, the HME supplier bills the SNF for the supplies.  The HME supplier usually charges SNF’s amounts in excess of the cost of the non-covered supplies in order to cover the cost of related services; such as inventory control, visits by customer service representatives, customized patient-specific packaging, etc.; plus overhead and profit.

In this case, SNF’s requested proposals for exclusive suppliers of items covered by the Medicare Program.  Bidders were also required to submit pricing for items not covered by the Medicare Program that SNF’s may purchase at their option.  The HME supplier wanted to submit bids offering pricing for the non-covered items and related services that were below the HME supplier’s costs.  The HME company acknowledged that the payments it would receive from Medicare Part B as SNF’s exclusive suppliers for covered items would more than offset any losses it would incur to furnish the non-covered items and related services below its costs.

In response to the suppliers’ request, the OIG first stated that the anti-kickback statute is implicated if any direct or indirect link exists between a price offered by a supplier or provider to referral sources for items or services that referral sources pay for and referrals of Federal business for which the supplier or providers can bill a Federal health care program.  According to the OIG, both referral sources and providers that receive referrals have obvious motives to trade below-cost payment rates for or free items and services for referrals of patients whose care will be paid for by the Medicare Program.

The OIG then pointed out that providers may be “swapping” the below-cost rates on certain types of business in exchange for other profitable Federal business from which providers can recoup losses incurred on the below-cost business.  The OIG stated that providers likely engage in such practices with the intent of inducing referrals of more lucrative business paid for by the Medicare Program.

It is worth considering this Advisory Opinion in light of the practices of some hospital discharge planners/case managers.  They may require post-acute providers to give services and/or supplies to patients for whom there is no payor source or payor sources that do not reimburse at rates that cover providers’ costs in order to receive referrals of patients whose care will be paid by the Medicare Program.  If post-acute providers are unwilling to render services free of charge, hospitals may bear the risk of continued care of such patients.  This type of “swapping” may also be prohibited by the OIG based upon the Advisory Opinion described above.

© 2011 Elizabeth E. Hogue, Esq.  All rights reserved. No portion of this material may be reproduced in any form without the advance written permission of the author.

Friday, September 9, 2011

What do you think of ICD-10?

There are many ICD-10 surveys out there, but none have focused on the home health community— until now.
We’re conducting an ongoing study of the home health community’s perceptions and preparations for the ICD-10 conversion, and want you to participate.  
By participating in our survey, you’ll be registered in a drawing for a 300-piece poker set, in honor of the National Association for Home Care (NAHC) Annual Conference in Las Vegas October 1-5, 2011.

This is the first survey (open between September 9, 2011- October 6, 2011) as part of our ongoing study leading up to implementation in October 2013.0

Share your opinions on ICD-10 here!

Thursday, September 8, 2011

NAHC Calls Selected Agencies to Participate in an Important Survey

The National Association for Home Care & Hospice (NAHC) urges agencies that have been randomly chosen to partake in the Delta National Study to Reduce Avoidable Hospitalizations through Home Care study. The largest of its kind in the history of home care, this study addresses one of the single biggest quality problem facing home care agencies.

More than 700 agencies are expected to be surveyed via a 30-minute phone interview. As a thank-you, NAHC will provide participants with a special webinar and advance report on the best practice findings.

The study is also one of the most collaborative efforts ever initiated in home care. It is being sponsored by Delta Health Technologies and co-sponsored by NAHC. Affiliate sponsor groups also include the Joint Commission, Community Health Accreditation Program (CHAP), and the American Physical Therapy Association, among others.

The results will be released at the NAHC Annual Meeting and then made available free to all home care agencies in the United States.

So, if your agency is called, we urge you to participate. It can benefit your agency and the entire home care field.