Compliance is truly a growing concern outside of the hospital environment. Expanded scrutiny is being applied by federal and state governments to the areas of the healthcare continuum beyond traditional acute care. We believe this extended focus shows no sign of relenting and may even become more intense as time goes by (AHA, 2019). Here are some examples of the increased scrutiny being paid to specific care environments:
The government now audits a targeted number of claims to establish a benchmark for individual home health organizations. If they identify a high level of claims that are not accurate, then they're going to provide one-on-one education to the provider. It's becoming more and more important that organizations not only have training for their staff members about their billing processes, but also about what constitutes fraud and what that looks like from a regulatory perspective (CMS, 2018).
One of the usual suspects for scrutiny in the hospice environment is eligibility. Typically, regulators are going to ask if a person meets the eligibility to be considered for hospice care. That answer should determine the different levels of care, from general inpatient, continuous care to home hospice or respite care. For regulators, long lengths of stays are a red flag. One example to consider is where patients were admitted to hospice and were still there after a year's time. That obviously may not meet the criteria for hospice and is likely to draw the scrutiny of the OIG and other governmental agencies (Baxter, 2018).
These organizations are drawing increased scrutiny for the quality of care they provide, especially for such purposes as rehabilitation and whether patients are getting the type of care that satisfies the quality measures that their health situations require. There’s an increased likelihood of the imposition of corporate integrity agreements related to skilled nursing facilities that are not meeting even the minimum quality of care standards. In some cases, organizations in this sector have been deemed to be providing worthless or unnecessary care. This care subset is an area experiencing very close scrutiny, and actions are being taken against some of these agencies as a result. Another focus is the medical necessity for therapy and whether a patient meets the criteria for receiving it, whether it is physical therapy, rehabilitation therapy, or even occupational therapy. It is important to note that long-term care regulations were recently updated in order to be consistent with current health and safety knowledge (CMS, 2007).
The OIG has placed a general focus on whether a caregiver has the qualifications and the competencies required by the care that they are providing. In other words, if there's a licensure or scope of practice indicator, do the individuals who are providing it meet those criteria? Also, staffing ratios—the number of patients to staff—themselves are very important. In assisted living facilities, the focus is on the quality of life and person-centered care. From the corporate integrity agreement (CIA) perspective, we've seen an increase in quality-focused CIAs over the last several years. CIAs typically focus on fraud, abuse, contracts and arrangements, anti-kickback or stark violations, or illegal transactions; however, quality of care is also being cited as cause for an enforcement action. These violations tie back to staff qualifications and competencies. A common question is whether a caregiver is delivering care within his or her scope of practice.
This blog post excerpts the HealthStream article, The Challenge of Translating Healthcare Regulations into Training Curricula, by Ben Diamond, Vice President of Compliance Solutions, and Debbie Newsholme, Senior Director of Content Development and Compliance Solutions, at HCCS, A HealthStream Company. The article also includes:
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