Enforcement Compliance Is Targeting Home Health, Hospice, and Nursing Homes

April 1, 2021
April 1, 2021

Compliance continues to be an area of extreme focus for the healthcare industry, including the care continuum. Where healthcare compliance professionals spend their time is changing as accrediting bodies and regulators find new areas that merit investigation. Healthcare’s low operating margins and tenuous financial health make it easy to say that compliance leaders need to split their attention between traditional activities and the where the future is headed.

In our efforts to identify new compliance directions, content experts from HCCS, A HealthStream Company, recently attended the Health Care Compliance Association’s 2018 Enforcement Conference. We’ve already blogged here about the first round of things they learned. Here is an excerpt from Round 2:

Enforcement Compliance: Home Health, Hospice, and Nursing Homes

Federal and state governments continue their close scrutiny of the post-acute sector. Listed below are the targeted areas discussed during this session:

  • Home Health:
    • Government audits and investigations—targeted probes and educational audits
    • Medical necessity
  • Hospice:
    • Eligibility
    • Levels of care
    • General inpatient care and continuous home care
    • Long lengths of stay
    • Patients in nursing homes or assisted living facilities (ALFs)
  • Skilled Nursing Facilities:
    • Quality of care
    • Medical necessity of therapy services
    • Office of Inspector General (OIG) focus—staffing records
  • Assisted Living Facilities:
    • Quality of care
    • Inconsistent reporting of deficiencies compared with Government Accountability Office (GAO) findings

Compliance Risk Areas for the Care Continuum

Risk areas within this space remain fairly consistent with medical necessity, kickbacks and inappropriate referrals, overbilling, insufficient documentation, staff training and education, credentialing and exclusions accounting for the major findings. Inappropriate billing accounted for $250 million for general inpatient care. The OIG Office of Audit Services is now auditing agencies and intends to publish findings. This will increase transparency for consumers when looking for facilities. Medicare Administrative Contractors (MACs) are now required to prepare an annual “Improper Payment Reduction Strategy.” The intent of this program is to identify those providers who show a pattern of overbilling and provide education and training in an effort to reduce occurrences. The MACs will analyze data by providers, services, and beneficiaries. Focus audits will be initiated based on this data. This action is mandated under the Affordable Care Act and as a part of the Medicare Strike Force initiative.

CIAs and Non-Hospital Healthcare

This session also addressed Corporate Integrity Agreements (CIAs) in the post-acute/continuum environment. The requirements for compliance are essentially the same as for the acute care sector. Although the presenters did touch on the financial, operational, clinical, and compliance costs in some detail, they focused on the impact of hiring and retaining an Independent Review Organization throughout the term of the CIA. These are all important considerations for organizations as they perform at a minimum, annual risk assessments. Along with the focus on the post-acute space comes the criminal aspect of healthcare fraud.


Download the article that summarizes learning from this HCCA Conference.