Happy Hump Day! Long title for what is going to be, a rather brief post.
As followers and regular readers know, my firm (I am the co-founder and part owner) H2 Healthcare, LLC has a practice area uniquely concentrated on clinical compliance and complex litigation support. The practice area is headed by Diane Hislop, RN (yes, we are related – married). Within our organization, we have over 100 years of expertise in clinical and regulatory compliance, including risk management, a new virtual compliance program for providers, litigation expertise (expert witness), due diligence on M&A (claims audits), post-survey support (appeals, IDR, etc.), Medicare claims audit work for probes and claim denials, plus extensive tools and education to assist with compliance issues. Given the complexity and breadth of ethics (corporate) and compliance issues in healthcare, our work continues to transition to identifying more avenues to assist providers on prevention or a proactive basis.
In that vein, I spend a fair amount of time researching issues that relate to compliance. There are multiple posts on this site related to compliance issues from survey to litigation.
In my research work, I often dig through non-healthcare information to qualify how other industries and trends worldwide are likely to impact healthcare. For today, I grabbed a report from LRN on Ethics and Compliance Programs and their effectiveness. The report is available here: LRN-2024-Ethics-Compliance-Program-Effectiveness-Report_Global
According to the report, the US Department of Justice has articulated that updated, comprehensive risk analyses are the basis for an effective ethics and compliance program in the Criminal Fraud Division’s Evaluation of Corporate Compliance Programs (ECCP). The ECCP is a set of guidelines for DOJ prosecutors to use in evaluating the strength and effectiveness of
corporate E&C programs. The DOJ’s evaluation of corporate E&C programs is a major factor in determining whether to
bring charges, as well as the severity of any fines or penalties imposed because of corporate misconduct. There are three
fundamental topics in the ECCP:
- Is the corporation’s compliance program well designed?
- Is the program being applied earnestly and in good faith? In other words, is the program adequately resourced and to function effectively?
- Does the corporation’s compliance program work in practice?
For healthcare, providers should see the parallel. CMS and the DOJ have directly and forcefully reiterated their belief that billing impropriety and potential fraud are widespread. CMS’ recent initiative to audit five claims (Medicare) from every SNF provider is an indicator of how virulent claims enforcement activity is within the Federal government.
The nexus between poor care, complaints, and ultimate claim recovery activity is more proximal today than ever. CMS has stated that a large percentage of claims, 15%, are paid improperly. The number one cause? Documentation for care and services provided is insufficient to support the claim. While improper payments include underbilling, that is never a trigger for audits or enforcement. More here: https://rhislop3.com/2023/06/01/snfs-get-ready-claims-audits-start-soon/
As in the attached report, and the message for today for providers is get your compliance programs into high gear. Integrate them with your QAPI and Resident Satisfaction programs to cross inform all functions, including survey work. Audits are required and providers should know, self-audits are not the standard by any means – outside audits are basically, required.
Happy Hump Day! I’ll post more on this topic soon. Suffice to say, a really good Ethics and Compliance Program is not a burden and shouldn’t be. It can be highly effective in maintaining billing integrity while enhancing, revenue integrity. It can and should, have a backbone of QAPI and staff education is important. Developing a culture of quality is also important and arguably, the most important factor, starting from the very top of the organization – Board and C-Suite.
There are a bunch of goodies, topically relevant, on this site. Here are a few of my faves!
- https://rhislop3.com/2023/09/07/five-quality-and-compliance-tips/
- https://rhislop3.com/2018/11/16/the-real-impacts-of-poor-quality-inadequate-compliance-and-weak-risk-management/
- https://rhislop3.com/2018/11/29/follow-up-real-impacts-of-poor-quality-and-lax-compliance/
- https://rhislop3.com/2019/06/14/the-connection-between-quality-and-revenue/
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