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Guidance for Effective Compliance Programs

While there is no “off-the-shelf” solution for meeting the Office of Inspector General’s (OIG) expectation that all health care organizations will have an “effective” compliance program, guidance exists for key elements that will be taken into account if your organization is ever accused of fraud or abuse.

Basic expectations for health care compliance programs were first outlined in the Federal Sentencing Guidelines in 1991, and later updated in 2004.  The intent of the sentencing guidelines was to ensure consistency in sentencing and promote good corporate citizenship by creating incentives for organizations to self-initiate crime prevention efforts.  The guidelines set forth seven basic elements and have become the de facto standard for compliance programs.  These elements are not only taken into account in terms of sentencing, but also form the framework for most Corporate Integrity Agreements (CIAs) that allow organizations to settle claims and avoid exclusion from Medicare and Medicaid programs.

If you’re not already familiar with the following seven elements, it will behoove you to do so.   And even if you’re familiar with them, it may be helpful to consider where you stand on achieving “effectiveness” in each of these areas across all of your service lines:

  • Implementing written policies, procedures and standards of conduct
  • Designating a compliance officer and compliance committee
  • Conducting effective training and education
  • Developing effective lines of communication
  • Conducting internal monitoring and auditing
  • Enforcing standards through well-publicized disciplinary guidelines
  • Responding promptly to detected offenses and undertaking corrective action

TCG’s Compliance QuickTips© series addresses each of these elements in greater detail and provides tips on how you can move beyond the bare minimum to establish a robust program of ethics and compliance for your organization.

For additional information, check out these resources:

OIG Health Care Compliance Program Tips

The seven pillars of an effective ethics and compliance program – Compliance Today, Health Care Compliance Association

OIG Compliance Guidance for Home Health Agencies

OIG Compliance Guidance for Hospices


Learn to Achieve High Marks in Quality Reporting

To comply with regulatory, reimbursement and quality requirements, hospice organizations must provide appropriate documentation.  How clinicians document today can have lasting effects on reimbursements in the future more so than ever before. In the whirlwind of dates, deadlines, guidelines and ominous warnings coming from the Centers for Medicare & Medicaid Services (CMS), it is easy for staff and administrators to feel uncertain about the newly required Hospice Quality Reporting. This pressing change will require leaders to reiterate the importance of education and value staff that stays in the know.

Continuing Education

These recent changes will force a more active approach to reporting. TCG CHEX eLearning is here to help you obtain and retain the knowledge to keep your operation under compliance. The fundamental lessons are:

  • Know all the acronyms and definitions of each metric to be reported. Being familiar with the subject matter is the key to reporting correctly.
  • Understand that for a while each case may require double checking your work until it becomes common knowledge company wide.

Courses Focused on Proper Documentation

TCG CHEX eLearning courses offer helpful guidelines to meet regulatory and compliance standards. The below courses are examples of the TCG CHEX eLearning courses offered for hospice:

Hospice 101

Hospice 201

Hospice Conditions of Participation Part I

Hospice Conditions of Participation Part II

Recorded Webinar: Hospice Item Set: A New Way of Thinking About Quality

Recorded Webinar: Documentation for Success: Hospice Eligibility

Take a free demo today and see how TCG CHEX eLearning can help your organization cultivate an environment focused on quality care.


Advisory groups, national associations call for suspension of new Part D requirements

Although it is important that the appropriate part of Medicare pay for medications used by hospice patients, inadequacies in the new system are having damaging effects. This is why national advisory commissions and associations are recommending the Centers for Medicare and Medicaid Services (CMS) slow down on requiring prior authorization before anymore beneficiaries suffer. The goal by these groups is to issue a regulatory proposal to establish an improved, consistent method for the coordination of drug coverage between hospices and Part D plans.

In a recent letter from Chairman Glenn Hackbarth of the Medicare Payment Advisory Commission (MedPAC) to CMS’s Administrator Marilyn Tavenner, he calls for the suspension of prior authorization, pointing to the added burdens on beneficiaries and their family members. The letter asks for a more seamless process for the coverage of drugs for patients enrolled in the Medicare hospice benefit. The National Association for Home Care & Hospice (NAHC) plans to express similar concerns to CMS on the hospice proposed payment rule for FY 2015. Read the NAHC report on the charge led by MedPac.