Emerging Issues in Home Care 2000 and Beyond Chris Anderson Gentiva Health Services Melville, New York Chris Anderson Gentiva Health Services Melville, New York Phil Bradley Long, Aldridge & Norman LLP Atlanta, Georgia

Emerging Issues HIPAA  Privacy, Security, Communications, & Cultural Behaviors PPS  Billing, Billing, Billing  Impact to cost reporting False Claims  Is it a new ball game? Patient Inducement  New restrictions, advisory opinions HIPAA  Privacy, Security, Communications, & Cultural Behaviors PPS  Billing, Billing, Billing  Impact to cost reporting False Claims  Is it a new ball game? Patient Inducement  New restrictions, advisory opinions Corporate Integrity Agreements  If you don’t have…. Credit Balance Issues Self- Disclosure  Or self suicide?

Who is affected by HIPAA? All health care organizations that process health data and/or transmit data electronically must comply  Health plans, payors and clearinghouses that process health data must comply  All health care providers electing to conduct covered transactions electronically must comply  Employers, public health authorities, life insurers, medical billing agencies, information system vendors, service organizations and others entities if conducting any of the covered transactions must comply All health care organizations that process health data and/or transmit data electronically must comply  Health plans, payors and clearinghouses that process health data must comply  All health care providers electing to conduct covered transactions electronically must comply  Employers, public health authorities, life insurers, medical billing agencies, information system vendors, service organizations and others entities if conducting any of the covered transactions must comply

What transactions are covered? Administrative and financial health care transactions:  Health claims & encounter data  Health claims attachments  Enrollment/ disenrollment in a health plan  Health plan eligibility  Health care payment and remittance advice  Health plan premium payments  Injury reports  Health claim status  Referral certifications and authorizations Administrative and financial health care transactions:  Health claims & encounter data  Health claims attachments  Enrollment/ disenrollment in a health plan  Health plan eligibility  Health care payment and remittance advice  Health plan premium payments  Injury reports  Health claim status  Referral certifications and authorizations

Compliance Deadlines 24 months from the effective date of the final rules Effective date is usually 60 days following publication of the rule Anticipate all rules to be published by the end of 2000 – Compliance necessary by early 2003 DHHS Schedule for Publication  Transaction and Code sets – published  Other Standards -- Final Rule Publication dates unclear but expected by end of summer months from the effective date of the final rules Effective date is usually 60 days following publication of the rule Anticipate all rules to be published by the end of 2000 – Compliance necessary by early 2003 DHHS Schedule for Publication  Transaction and Code sets – published  Other Standards -- Final Rule Publication dates unclear but expected by end of summer 2000

Penalties for Noncompliance Severe Civil and Criminal Penalties for Noncompliance  Fines up to $25K for multiple violations of the same standard in a calendar year  Fines of up to $250K and/or imprisonment up to 10 years for knowing misuse of individually identifiable health information Severe Civil and Criminal Penalties for Noncompliance  Fines up to $25K for multiple violations of the same standard in a calendar year  Fines of up to $250K and/or imprisonment up to 10 years for knowing misuse of individually identifiable health information

Costs Compliance will be very costly and must be budgeted It has been estimated that compliance with HIPAA will consume 33 cents of every health care dollar between now and 2003 Hardware & Software Costs  Encryption, Privacy, Monitoring Systems Operational Costs  Teaching and Training  Changing Behaviors  Monitoring of access and usage Compliance will be very costly and must be budgeted It has been estimated that compliance with HIPAA will consume 33 cents of every health care dollar between now and 2003 Hardware & Software Costs  Encryption, Privacy, Monitoring Systems Operational Costs  Teaching and Training  Changing Behaviors  Monitoring of access and usage

HIPAA Compliance Preparation Raise organizational awareness Create a leadership plan to oversee the development and execution of appropriate plan Develop a systematic plan of evaluation and action related to compliance with the regulations Dedicate resources to the implementation of a strategic plan to address the requirements of the legislation Discuss the implications of the regulations and create a compliance plan Develop a plan to educate employees regarding the new regulations Marketing/PR strategy to address patient/ client/ customer concerns Raise organizational awareness Create a leadership plan to oversee the development and execution of appropriate plan Develop a systematic plan of evaluation and action related to compliance with the regulations Dedicate resources to the implementation of a strategic plan to address the requirements of the legislation Discuss the implications of the regulations and create a compliance plan Develop a plan to educate employees regarding the new regulations Marketing/PR strategy to address patient/ client/ customer concerns

HIPAA Compliance Preparation (Continued) Engage outside consultants or vendors if necessary Review and assess existing systems, policies and procedures Develop and revise policies and procedures Commence modification of existing systems to comply with the regulations Examine contracts with 3 rd parties to determine compliance Review impact on relationships with customers, clients, etc. Review insurance policies to determine current/future coverage for breaches of confidentiality Address potential legal liability and risk management issues

Prospective Payment System Fraud and abuse elements  Upcoding  False Claims  Utilization standards  Cost report compliance  Patient Dumping Issues Learn from the hospital DRG system (400 + CIA’s) Fraud and abuse elements  Upcoding  False Claims  Utilization standards  Cost report compliance  Patient Dumping Issues Learn from the hospital DRG system (400 + CIA’s)

Audit Goals for PPS More than ever audits will be driven from a clinical standpoint Through out the traditional analysis approach No longer talking about straight technical issues Billing systems will play an integral role in audit approach More than ever audits will be driven from a clinical standpoint Through out the traditional analysis approach No longer talking about straight technical issues Billing systems will play an integral role in audit approach Prospective auditing (Pre- bill release)  Oasis  HHRG  Grouper  Utilization Standards  Care Protocols 90 day window of opportunity for full implementation of billing filters at the FI’s.

PPS Compliance Preparation No existing best practices  Learn and not learn from hospital experience. Training is key  Billing Training Including: Coding Oasis Medicare Coverage HHRG System Gaming  All clinical- billing staff No existing best practices  Learn and not learn from hospital experience. Training is key  Billing Training Including: Coding Oasis Medicare Coverage HHRG System Gaming  All clinical- billing staff Risks:  Patient Complaints  Caregiver Complaints  Utilization is the driver Communication plan Hotline response system and its tie to compliance System analysis RAP/Claim release process

PPS Compliance Preparation Operational difficulties  RAP & Cash Flow versus Compliance  Physician orders- Verbal start of care orders  Significant drops in utilization- impact Risks  False Claims  Medical Review  FI- CERT Program  Trending analysis- ORT Operational difficulties  RAP & Cash Flow versus Compliance  Physician orders- Verbal start of care orders  Significant drops in utilization- impact Risks  False Claims  Medical Review  FI- CERT Program  Trending analysis- ORT

False Claims Civil Monetary Penalties  Risks Billing System Changes (PPS) Stronger intervention by MFCU’s CERT Program  New Requirements have no bearing on the establishment of CIA’s  Effect on Qui Tam actions unknown  Age old issue- The Rules in Conflict – COP’s, Kickback, False Claims, etc. Civil Monetary Penalties  Risks Billing System Changes (PPS) Stronger intervention by MFCU’s CERT Program  New Requirements have no bearing on the establishment of CIA’s  Effect on Qui Tam actions unknown  Age old issue- The Rules in Conflict – COP’s, Kickback, False Claims, etc. Keys to Compliance:  Billing Audits Prospective Retrospective  Relationship with FI Process for handling errors Proper reporting  Training  Disciplinary Consistency

Patient Inducements Advisory Opinion  Medical related items not permitted Pagers Beepers Child helmets  PPS issue (cherry-picking)  Waiver of Co-payments Advisory Opinion  Medical related items not permitted Pagers Beepers Child helmets  PPS issue (cherry-picking)  Waiver of Co-payments Compliance Preparation  Sales Training  Contract Training  Audit performance Sales Co-payments Other waivers Collaterals Bonus Structures and Performance Criteria

Corporate Integrity Agreements Home Care Model  Training General Contracts Cost Reporting Billing  Audits Billing  Structure after PPS  IRO Engagement Home Care Model  Training General Contracts Cost Reporting Billing  Audits Billing  Structure after PPS  IRO Engagement Compliance Implementation  Successful negotiation  Mirror existing compliance program  Demonstrate adequacy of established safeguards  Involvement of senior management  Building the culture of proactive compliance versus the “mandated & dreaded” compliance model

Credit Balances Compliance Preparation  Define credit balances clearly  Identify credit balances and eliminate co-mingling  Have a policy you can execute  Repay true credit balances within 30 days of credible evidence  How long is to long to research?  Train, Audit, Enforce Compliance Preparation  Define credit balances clearly  Identify credit balances and eliminate co-mingling  Have a policy you can execute  Repay true credit balances within 30 days of credible evidence  How long is to long to research?  Train, Audit, Enforce

Self Disclosure Is it self suicide? How many forms does this take? What is a self disclosure? Is there practical lessons already learned? Is it self suicide? How many forms does this take? What is a self disclosure? Is there practical lessons already learned? Compliance Points  Develop key contacts and relationships within the payer community  Close relationship and openness with the FI  Distinguish errors and inappropriate activity  Minimize the need for disclosure at higher levels of the enforcement ladder State FI AG OIG FBI

Closing Comments Chris Anderson Chris Anderson Phil Bradley