TCG QuickTips© for Success

TCG QuickTips© provides thought provoking ideas and useful solutions for the challenges you face as a home care and hospice leader.

TCG QuickTips Archive

Purpose and Goals for an Effective Code of Conduct

A Code of Conduct is the foundation of an effective organization-wide compliance program.  It provides a map for employees, directing them to use organizational values in their daily decision making.

An effective Code of Conduct should:

  • Incorporate organizational values
  • Improve awareness of compliance risks
  • Determine wrongdoing and promote honest and ethical conduct
  • Identify clear methods of reporting compliance concerns
  • Increase employee and key stakeholders’* trust in the organization’s commitment to compliance

To ensure relevance and dissemination, the Code of Conduct should be:

  • Readable and accessible to employees and key stakeholders*
  • Reviewed annually to incorporate latest developments in laws, regulations and risk areas
  • Included in initial orientation training
  • Acknowledged by all employees and key stakeholders annually

A thoughtful, well written Code of Conduct will serve the organization and the employees by providing guidance and reinforcing the organization’s commitment to compliant and ethical behavior.

*Key Stakeholders: see below for further considerations regarding stakeholders

For additional resources, check out these websites:

SAI Global Whitepaper

OIG Compliance Program, Guidance for Hospices

OIG Compliance Program, Guidance for Home Health Agencies

Key Stakeholders

When drafting compliance documents, such as the Code of Conduct or policies and procedures, and when considering how best to educate and enforce, it is important to decide how you will address all key stakeholders related to your organization.  These may include:

  • Employees *
  • Owners (if applicable)
  • Board members
  • Volunteers
  • Joint venture partners
  • Vendors of outsourced services
  • Other vendors

* Depending upon the size of your organization, employees could be further segmented by job function or geographic area.

You may decide to develop one document applicable to all stakeholders, individual documents geared to a certain group of stakeholders, or a document that is generic but may have different elements such as a cover letter to a Code of Conduct that is targeted toward different audiences.

The bottom line is that you want to ensure that all stakeholders are addressed and brought into your compliance program.

Prepare. Reinforce. Go Further.

TCG Compliance Solutions is ready to assist you in implementing and enhancing effective controls and best practices for seamless compliance.

Contact us for the necessary expertise, resources and tools to improve and maintain compliance.

 

TCG Compliance QuickTips © – 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:

Prepare. Reinforce. Go Further.

TCG Compliance Solutions is ready to assist you in implementing and enhancing effective controls and best practices for seamless compliance.

Contact us for the necessary expertise, resources and tools to improve and maintain compliance.

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

So You’ve Merged, Partnered or Affiliated … Now What?

Post acquisition integration is a significant and sometimes underestimated step of an acquisition process. Integration is a critically important phase to ensure the value of the acquisition is captured. This requires careful attention to employees, customers and stakeholders.

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  • Develop a clear integration plan.
  • Pay particular attention to areas identified during due diligence that need re-enforcement or direct attention such as clinical documentation, training, communications, marketing and operational and financial improvements.
  • Consider what areas should be standardized or centralized such as electronic medical records, policy and procedures, compliance, human resources, billing, intake, etc.
  • Remember to address staff retention and notification of required legal entities (CMS, accrediting bodies, state departments of health, etc).

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TCG experts help ensure your investment by building the following into your integration strategy planning and implementation plan:

Operational performance assessment and integration

Financial performance assessment and integration

HR assessment and integration

Communications and marketing assessment and integration. Carefully crafting the transaction message is vital to help internal and external stakeholder retention

Compliance assessment and integration

Click on the following links:books

Mergers, Acquisitions, Due Diligence and Valuations

Consulting

Strategic Positioning

Interim and Transitional Management

About the Author

Jen AitkenJennifer M. Aitken, MBA, Director of Consulting Services

Ms. Aitken, Director of Consulting for The Corridor Group, has more than 15 years of experience in hospice and senior living communities. Alongside her varied roles, she has overseen corporate integrity activities and overall agency risk management, maintained agency compliance with federal and state regulations, policies and procedures, licenses and accreditations, facilitated regulatory and accreditation encounters, analyzed agency success using satisfaction surveys, incident reports, chart reviews and regulatory reports, lead performance improvement project teams, and co-lead feasibility, development and opening of a hospice inpatient unit.

TCG Compliance QuickTips © – Do You Have the Proof to Successfully Defend Your Compliance Program?

“Documentation is the key to demonstrating the effectiveness of a provider’s compliance program.”
– OIG Compliance Guidance

A strong and well-documented compliance program will help identify problems when they are small and manageable and will help an organization defend itself if they become the target of a government investigation.

The DOJ identified factors for consideration when deciding whether to prosecute companies:

“While the Department recognizes that no compliance program can ever prevent all criminal activity by a corporation’s employees, the critical factors in evaluating any program are whether the program is adequately designed for maximum effectiveness in preventing and detecting wrongdoing by employees and whether corporate management is enforcing the program or is tacitly encouraging or pressuring employees to engage in misconduct to achieve business objectives. The Department has no formulaic requirements regarding corporate compliance programs. The fundamental questions any prosecutor should ask are: Is the corporation’s compliance program well designed? Is the program being applied earnestly and in good faith? Does the corporation’s compliance program work?”

The OIG recommends documenting the following to support your compliance efforts:

  • Audit scope, findings and actions
  • Hotline calls and their resolutions
  • Corrective action plans
  • Any investigations undertaken in response to compliance concerns
  • Employee training (including content and number of hours)
  • Disciplinary actions
  • Modification and distribution of policies and procedures (including Code of Conduct)
  • Evidence of refunds of overpayments and any self disclosures

It is clear the DOJ and OIG place strong emphasis on the “effective” part of a compliance program.  Documenting all of your organization’s efforts will lend credibility to your claims of a “culture of compliance.”  While you may have all 7 Elements of an Effective Compliance Program, can you produce documentation to support effectiveness?  Frequently, compliance documentation is limited to audit results, hotline reports and investigation results.  Complete compliance records include all of the items listed above and should be readily accessible.  The ability to demonstrate all of the activities of the Compliance Department will be invaluable in a defensive position.

Be thorough, and sleep well!

For additional Resources, check out these websites:

Prepare. Reinforce. Go Further.

TCG Compliance Solutions is ready to assist you in implementing and enhancing effective controls and best practices for seamless compliance.

Contact us for the necessary expertise, resources and tools to improve and maintain compliance.

 

Where is your PEPPER?

Did you download your Q4FY13 Hospice Program PEPPER (available for download as of April 21, 2014) If so, congratulations! Well done for taking the first step! Have you taken the next step to review the report and determine how you can use the information to support your auditing and monitoring efforts?

About PEPPER

Program for Evaluating Payment Patterns Electronic Report (PEPPER) is provided at no cost by CMS. The report contains one hospice’s Medicare paid claims data statistics for areas that may be at risk for improper Medicare payments. PEPPER does not identify improper payments; it is an educational tool that is intended to help providers assess their risk for improper Medicare payments.

PEPPER compares a hospice’s Medicare data with aggregate Medicare data for the state, MAC jurisdiction and nation for two target areas: live discharge and long length of stay. A hospice’s billing pattern for each target area is reflected as a percentage; but more useful information comes from knowing how it compares to other hospices, which is calculated by percentiles. A percentile is a statistical measure. For example, the 80th percentile is the value (or score) below which 20 percent of the observations may be found.

If a target area for the hospice is at or above the national 80th percentile, the hospice is identified as at risk for improper Medicare payments.

How can PEPPER be useful to your hospice? Regardless of your program’s percentile ranking:

  • Share the data internally
  • Use the percentiles to compare your hospice’s results with national, jurisdiction and state to prioritize auditing and monitoring
  • Track ranking over time and identify root causes of material changes
  • Use your analysis to provide targeted education and/or process enhancements

Reference: http://www.pepperresources.org/LinkClick.aspx?fileticket=Gmn4md7nl3s%3D&tabid=61

Source: http://pepperresources.org/LinkClick.aspx?fileticket=IOo83GXWqI4%3d&tabid=155

 

TCG can help you analyze and respond proactively to your PEPPER findings

Click on the following links:books

How TCG can help

Tools to maintain hospice compliance

TCG’s White Paper on Bundled Payment

 

About the Author

Jennifer M. Aitken, MBA, Director of Consulting Services

Jen AitkenMs. Aitken, Director of Consulting for The Corridor Group, has more than 15 years of experience in hospice and senior living communities. Alongside her varied roles, she has overseen corporate integrity activities and overall agency risk management, maintained agency compliance with federal and state regulations, policies and procedures, licenses and accreditations, facilitated regulatory and accreditation encounters, analyzed agency success using satisfaction surveys, incident reports, chart reviews and regulatory reports, lead performance improvement project teams, and co-lead feasibility, development and opening of a hospice inpatient unit.

TCG Compliance QuickTips © – Repay or Self-Disclose? …That is the Question!

What is the appropriate action if you determine that a claim was improperly billed?

A. Follow normal repayment channels

B. Complete Self-Disclosure Protocol (SDP)

C. Do nothing with the bill but take corrective action to prevent future improper billing

Luckily for us, the OIG has provided guidance.

For claims where errors have been discovered but there was no “credible evidence of misconduct,” the OIG states: “Where potential fraud or False Claims Act liability is not involved, the OIG recommends that normal repayment channels should be used for returning overpayments to the government as they are discovered.” Examples of this may be the discovery of missing a Face-to-Face encounter, incomplete certification or recertification or other documentation errors. If errors are found, it is expected that the provider will repay the government and quickly implement corrective actions to prevent future errors.

SDP is reserved for more serious situations. The OIG provides this guidance: “If the compliance officer, compliance committee, or management official discovers credible evidence of misconduct from any source and, after a reasonable inquiry, has reason to believe that the misconduct may violate criminal, civil, or administrative law, [the organization] should promptly report the existence of misconduct to the appropriate Federal and State authorities within a reasonable period, but not more than 60 days after determining that there is credible evidence of a violation.”

It is strongly recommended that SDP be conducted with the assistance of counsel since it is a complex process and an admission of misconduct.

Answer: Either A or B is correct, depending on the situation. C is never a good idea.

For additional Resources, check out these websites:

Prepare. Reinforce. Go Further.

TCG Compliance Solutions is ready to assist you in implementing and enhancing effective controls and best practices for seamless compliance.

Contact us for the necessary expertise, resources and tools to improve and maintain compliance.

How to Conduct an Effective Compliance Investigation

Conducting an effective compliance investigation is a methodical process. A fair and impartial investigation is conducted with integrity and respect for all involved parties. To be effective, the investigation should be conducted timely and with adequate preparation. If there is a potential for further harm, take remedial action immediately and until the investigation is complete. In allegations of serious wrongdoing, it is possible that an investigation should be conducted under attorney-client privilege.

When preparing for an investigation, consider the following:

  • Review the complaint and chronology of events
  • Review applicable internal documents including policies and procedures and the organization’s Code of Conduct
  • Compile a list of witnesses including both the person reporting the concern (the relator) and the accused, then determine the order in which the interviews should be conducted
  • Review background information, such as the employment information of the relator and the accused
  • Review any prior related reports
  • Develop questions ahead of the interview (who, what, when, where, how)
  • Identify any additional documents that may be relevant such as, time cards, incident reports, contracts, agreements, corrective action reports, etc.
  • Identify the goals of the investigation
  • Determine if there are legal issues that need the involvement of counsel
  • Establish the time frame to conduct the investigation, the seriousness of the allegation, the potential for additional harm, the potential for retaliation, etc.

When conducting interviews, always remain neutral, stay focused and gather as much information as possible. Retain any notes that are taken. In taking notes, use care to document relevant facts without bias. If behavior is notable, document your observations, not impressions. When deciding what to document or save, consider the impact if the information was later introduced as evidence in legal proceedings.

Once all the evidence is gathered and interviews are completed, review the documentation for consistency and merit. When a final decision is made, facts should be documented concisely. If the complaint is substantiated, take steps to prevent its recurrence and make sure disciplinary action is fair and follows organization guidelines.

For additional Resources, check out these websites:

Prepare. Reinforce. Go Further.

TCG Compliance Solutions is ready to assist you in implementing and enhancing effective controls and best practices for seamless compliance.

Contact us for the necessary expertise, resources and tools to improve and maintain compliance

Reporting of Compliance Issues: How Do You Rate?

Reports of compliance issues come from a variety of reporting channels: hotline calls, emails, fax, direct mail, conversations and others. To track the number of reports your organization has received, include all reporting methods to give an accurate measure of your volume. NAVEX Global compiled a report entitled “The 2013 Ethics and Compliance Hotline Benchmark Report.” This report compiled data on 8,000+ clients representing 40 million employees. According to the report the normal range of unique reports per 100 employees in 2012 was 0.3 to 6.5. The median for healthcare was 1.5.

To calculate your reporting rate, follow this formula:

TCG-Compliance-QuickTips-Reporting-of-Compliance-Issues-How-Do-You-Rate

 

 

 

If you fall outside the normal range, it may not indicate a problem, but it should warrant further investigation.

The NAVEX Global report also indicates the average number of substantiated or partially substantiated reports in 2012 was 38%. The substantiation rate was the same for repeat reporters and first time reporters; so don’t discount your repeat callers. Substantiation rates were lower for anonymous reporters than those with a named reporter, but that may relate to the ability to gather additional pertinent information.

Make sure employees are aware of your reporting methods and that those methods are accessible and user friendly. Evaluate your program at least annually, benchmarking against prior years and against other organizations, if possible.

For additional Resources, check out these websites:

Prepare. Reinforce. Go Further.

TCG Compliance Solutions is ready to assist you in implementing and enhancing effective controls and best practices for seamless compliance.

Contact us for the necessary expertise, resources and tools to improve and maintain compliance.

Is Your Auditing Really Making a Difference?

“If you cannot measure it, you can not improve it.” – Sir William Thomson

From a compliance perspective, what change would have the most positive impact on your organization? And equally important, could you demonstrate that it was a positive change?

Auditing is only meaningful if the data gathered is used to drive improvement, and improvement must be measured to be meaningful. Collect data on a small number of key indicators such as documenting eligibility, face-to-face documentation or diagnosis coding. Choose whatever your organization considers risk areas.

Once you have baseline information, share that data with key personnel and leadership and discuss where compliance efforts would have the most benefit. When the indicator is chosen, set goals and share that information throughout the organization. Solicit input on ways to make improvements. It is much easier to garner buy-in when the suggestions come from those who will be responsible for implementing the changes!

Implement the changes that make the most sense to drive improvement. Then audit again to measure the improvements made. For a greater impact, consider posting team and individual results. Don’t forget to reward those that have exceeded their goals, even if it is just a verbal affirmation.

For additional Resources, check out these websites:

Prepare. Reinforce. Go Further.

TCG Compliance Solutions is ready to assist you in implementing and enhancing effective controls and best practices for seamless compliance.

Contact us for the necessary expertise, resources and tools to improve and maintain compliance.

Are Your Direct Operating Costs Competitive?

Labor and care delivery-related costs constitute the majority of expenses for a home health agency and offer the greatest opportunities for improved efficiencies. Organizations need to tightly control both direct and indirect labor expenses if they are to be successful in the future. Participation in bundled payment arrangements, whether as part of a patient episode of care across an acute and post-acute setting or limited to the post-acute care settings, will require home health agencies to operate at maximum cost efficiency while delivering outstanding patient outcomes.

How Do Your Agency’s Direct Operating Costs Compare to the National Median and Best Practice?

1. What are your agency’s direct labor costs (visiting staff’s wages, benefits, and contractor fees) as a percentage of net revenue? If your costs are greater than the national median or among the best 25% of national agencies, there is opportunity for improvement.

a. National Median: 45.1%

b. Best 25%: 34.5%

2. What are your agency’s direct transportation costs (mileage or fleet, payments) as a percentage of net revenue? If your costs are greater than the national median or among the best 25% of national agencies, there is opportunity for improvement.

a. National Median: 3.5%

b. Best 25%: 1.5%

3. What are your agency’s medical supply costs per episode? If your costs are greater than the national median or among the best 25% of national agencies, there is opportunity for improvement.

a. National Median: $34

b. Best 25%: $11

Source: BKD 2012 Medicare Cost Report Analysis http://www.bkd.com/industries/health-care/home-care-hospice/

 

Click on the following links:

 

About the Author

Sue Squibb

Ms. Squibb, Director of Consulting Services for The Corridor Group, has more than 30 years of experience in the delivery of home care and hospice services in both the private and non-profit sectors. As CEO and COO of home care subsidiaries of large, regional, integrated health systems, Sue has worked extensively with boards of directors and operational teams in the successful development and execution of mission, vision and strategic/operating plans.

Spin Your “ADR Straw” into “Compliance Gold”

“The people who get on in this world are the people who get up and look for the circumstances they want, and, if they can’t find them, make them.” – GB Shaw

If you are like most providers right now, you are spinning in circles. Most likely you are trying to keep up with all of the record requests from government contractors, drafting responses and compiling appeals. Resources are limited, and as a result, you are probably spending more time being reactive than proactive. Setting aside time to work through an annual compliance plan, including auditing, may have fallen low on your “To Do” list.

It is possible to have a solid compliance program in spite of the labor-intensive “projects” that pre-occupy your day-to-day existence. There’s a golden opportunity to incorporate your current activity into the audit and training components of your compliance plan. If you are responding to audits or edits, or whatever the contractor is asking for, you are already looking at records and identifying opportunities for improvement. Roll that up into your Work Plan and give your company credit for its efforts!

  • When preparing records for submission, take note of areas that need documentation improvements
  • Develop meaningful and thoughtful training programs around those weaknesses
  • Make completion of the training mandatory for all involved positions and track that education
  • Set high expectations and increase accountability at all organizational levels
  • Measure for improvement – hopefully not through responding to another round of record requests

Change is not easy and most of us will quickly “revert back” to our comfort zone. Keep monitoring to make sure improvements are sustained.

For additional Resources, check out these websites:

Prepare. Reinforce. Go Further.

TCG Compliance Solutions is ready to assist you in implementing and enhancing effective controls and best practices for seamless compliance.

Contact us for the necessary expertise, resources and tools to improve and maintain compliance.

The Importance of a Consistent Monitoring Process

The sixth element of an effective compliance program is ongoing auditing and monitoring activities. While auditing typically involves the concurrent or retrospective review of identified risk areas, monitoring is about the day-to-day activities and processes we use to make sure we are compliant. The OIG devotes much more ink to auditing in their Compliance Guidance, but it is the initial monitoring activities that produce good audit results.

Monitor transitive verb – to watch, observe, listen to, or check (something) for a special purpose over a period of time (Merriam-Webster Digital Dictionary)

A few examples of monitoring activities:

  • Verifying employees, contractors and physicians against the OIG Exclusion List (physicians are frequently overlooked)
  • Confirming appropriate signatures, dates and documentation prior to billing for services
  • Verifying that patient visits are scheduled appropriately and according to the plan of care
  • Ensuring appropriate staffing levels to meet the needs of the patient population

Of course, these activities can later be audited but let’s look at the monitoring process. Notice the term process.

Process noun – a series of actions that produce something or that lead to a particular result (Merriam-Webster Digital Dictionary)

As compliance professionals, we are looking for a particular result from our monitoring activities. To make sure our results are consistent, we need to ensure our processes are consistent. In other words, processes should be written, especially those that relate to monitoring activities. Belief that a process was in place is not a good defense, and “informal” or “unwritten” processes create unnecessary risk.

For additional Resources, check out these websites:

Prepare. Reinforce. Go Further.

TCG Compliance Solutions is ready to assist you in implementing and enhancing effective controls and best practices for seamless compliance.

Contact us for the necessary expertise, resources and tools to improve and maintain compliance.

Effective Monitoring: Avoiding the “Jack-In-The-Box”

“The extent and sincerity of an organization’s efforts to confirm its compliance often proves to be a revealing determinant of a compliance program’s effectiveness.” – OIG Compliance Guidance

Those of us that have been around a while may remember a childhood toy called “Jack-In-The-Box.” You know, you crank the handle and pretty music plays…then suddenly a scary clown pops out of the box and startles us into fits of crying. There is a reason this toy has lost popularity!

Surprises are especially unpopular in the healthcare industry. Here we are, going about our daily activities, and thinking all is well. Then – Pop! Where did that come from?! (Think government contractors conducting audits.)

Healthcare providers are perceived to have done a poor job of monitoring their activities for compliance with rules and regulations. As a result, decisions have been made to monitor providers much more closely by paying contractors to find our errors. (Actually, providers are paying for these audits through repayments and penalties.) The penalties imposed when these contractors find errors can be staggering!

The best defense: find our own errors. Great auditing and monitoring activities can be developed based on your risk assessments. When developing your risk assessment, be sure to include all areas of risk such as:

  • Risk areas identified by the HHS Office of Inspector General (OIG)
  • Areas under review by government contractors such as RACs, MACs, MICs, and ZPICs
  • HHS OIG Work Plan activity and semi-annual reports to Congress for the prior few years – these will show up in future government contractor audits
  • Findings from Office of Civil Rights (OCR) HIPAA and HITECH audits
  • Internally-identified risk areas – such as hotline reports or internal documentation reviews
  • Proof of an effective auditing and monitoring program will be critical if you are called on to defend your activities.

A risk assessment can certainly be done internally, but consider hiring an external organization such as TCG to conduct a baseline assessment. A benefit to an external auditor is fresh eyes that know current audit trends and areas of focus. An external auditor may find that there are inconsistencies in required language between different versions of forms at your organization. Sometimes organizations don’t observe what may be obvious to a third-party reviewer. Whatever method your organization pursues, now is the time to conduct a baseline assessment. Before a government contractor starts to crank that handle, know what is in that box!

For additional Resources, check out these websites:

Prepare. Reinforce. Go Further.

TCG Compliance Solutions is ready to assist you in implementing and enhancing effective controls and best practices for seamless compliance.

Contact us for the necessary expertise, resources and tools to improve and maintain compliance.

Don’t Let Your Guard Down!

Whether you’re boxing or fencing or providing home health or hospice care, it’s never wise to let your guard down. The recently announced ‘pause’ in RAC audits has received a lot of press, but scrutiny for home care providers by MACs and ZPICs are unaffected by the ‘pause,’ and their audits will continue unabated for home health and hospice providers. A new RAC with a dedicated focus on home health, hospice and HME is in the works and will be up and running before too long.

CMS Change Request 4825, effective March 6, 2014, ups the ante even further. This change authorizes contractors who determine that one claim does not meet Medicare payment criteria to also deny any related claim without requesting additional documentation. The National Association for Home Care and Hospice (NAHC) cautions that this policy change could have significant implications for home health and hospice providers since they often submit multiple claims for a single incident of illness – for example, submitting claims for several episodes for home health services or several months for hospice care.

Effective documentation and monitoring has never been so critical. Ensure your staff understands how to document right the first time, and make sure you have processes in place to prevent problems before they become pervasive. Click here for more information.

TCG can help you avoid a cycle of denials and appeals. We can provide clinical documentation experts to help you conduct one-time or recurring third-party reviews and/or test your processes.

  • Clinical and Billing Record Reviews
  • OASIS, diagnosis coding and HHRG integrity for Medicare home health PPS
  • Hospice LCD and Eligibility
  • Pre-billing Reviews
  • Documentation Training
  • Process Design and Training

Check out TCG’s self-help resources:

About the Author

William C. Musick, BS, MBA, CHC

Mr. Musick is a Senior Associate and Project Manager with The Corridor Group and has over 20 years of experience in health care operations management, financial and systems analysis and project management. He is a licensed consultant with the Standards for Excellence Institute and is also certified by the Compliance Certification Board in Healthcare Compliance (CHC). Bill is an expert in feasibility analysis for the development of hospice and end-of-life care services, facility planning and development, strategic planning and financial risk/benefit analysis. He also works with chief executives and boards of directors to achieve new levels of effectiveness in the governance of public benefit organizations. Bill has a special interest in supporting home health and hospice providers develop and sustain a culture of compliance.

Screening Employees and Contractors for Past Compliance Failures

“There are no shortcuts to any place worth going.” – Beverly Sills

The OIG’s Compliance Guidance expects providers to screen employees and contractors. Will your process hold up to governmental scrutiny?

The Affordable Care Act increases CMS authority regarding oversight of screening and compliance for new providers and new employees, and, at last count, 36 states had some requirement for background screening of healthcare workers that have direct access to patients. The federal government is currently moving toward national requirements and has completed a pilot program in this area.

There is a lot of confusion around requirements to check the OIG’s List of Excluded Individuals and Entities (LEIE). At present, there is no current federal requirement that employers verify employees against this list, yet there are stiff penalties if your organization hires an excluded individual. Those penalties include repayment for all services provided by the excluded individual and civil monetary fines. In addition to screening employees, any organization with whom a provider contracts should also be screened against the LEIE.

A State Medicaid Director letter dated January 16, 2009 advised states to require that providers search the OIG’s LEIE database monthly. Some states have implemented this requirement for Medicaid providers. As a result, it is best practice to check all employees at hire and monthly.

Note: There are a number of considerations to take into account in using the LEIE.

Click here for OIG tips regarding exclusion checks.

Apart from checking the LEIE, it is important to have a policy governing what prior convictions would exclude an individual for hire in your organization. The policy should also include specific details related to “provisional hiring” that spell out under what conditions an employee can begin work after an initial screening but before all background screening is completed. Some states have a specific list of exclusionary convictions. Be aware of your state’s requirements and incorporate those in your policies.

“If you don’t have time to do it right, when will you have time to do it over?” -John Wooden

For additional Resources, check out these websites:

Evaluation of the Background Check Pilot Program

Evaluation of the Background Check Pilot Program Appendices

Three years after final rule, CMS set to launch fingerprinting effort aimed at Medicare fraud

Fingerprint Based Background Checks for Medicare Provider/Supplier Fraud

OIG Compliance Program, Guidance for Hospices

OIG Compliance Program, Guidance for Home Health Agencies

An Effective Disciplinary Process

“If you don’t know where you are going, you might wind up someplace else.”
-Yogi Berra

Managing disciplinary procedures can be intimidating, even for those who have experience. It is helpful if leadership has a well thought out process that is designed with a focus that encourages employees to improve. It can be a roadmap or template for navigating a difficult situation. A well-crafted and well-executed procedure will give confidence to leadership as well as earn respect from employees.

A comprehensive disciplinary process should address the following three areas:

  • Investigation
  • Expectations for Improvement
  • Documentation

Click here for a more detailed Checklist.

Once the employee correction has been addressed, the organization should then determine if this was an isolated incident or if there is a systemic problem that needs to be addressed. If needed, the findings from the investigation may be included in the organization’s risk assessment, annual work plan, and ongoing education.

“We are continually faced with great opportunities brilliantly disguised as insoluble problems.”
- Lee Iacocca

For additional resources, check out these websites:

Prepare. Reinforce. Go Further.

TCG Compliance Solutions is ready to assist you implement and enhance effective controls and best practices for seamless compliance.

Contact us for the necessary tools, resources and expertise to reach compliance efficiency.

Your Arsenal of Corrective and Disciplinary Actions

“Discipline is the bridge between goals and accomplishment.” Jim Rohn

Not only is it impossible to address every possible violation in disciplinary guidelines, it’s not expected.

OIG Compliance guidance states that “each situation must be considered on a case-by-case basis to determine the appropriate sanction.” Cases of minor misconduct are often best handled informally. Whereas more serious situations, or where an informal approach has been unsuccessful, formal action is appropriate.

Responses to compliance lapses may be in the form of corrective action and/or disciplinary action. When developing your disciplinary program, you may wish to provide for the following range of actions:

Corrective Action

  • Verbal
  • Counseling
    • Warning
    • Reprimand
    • Written Notice of Counseling
  • Performance Improvement Plan
  • Letter of Reprimand

Disciplinary Actions

  • Demotion
  • Suspension without pay
  • Dismissal

It may also be necessary to suspend an employee with pay during the course of an investigation if the presence of that employee would hinder the investigation. If this is the case, there is increased urgency in obtaining a resolution quickly, for the benefit of all involved.

Of course, if your organization has a Human Resources Department or General Counsel, you should include them in defining the disciplinary process and in taking action in response to a lapse. Also, as noted elsewhere in TCG Compliance QuickTips©, disciplinary policies should include an appeal process and be well communicated at all levels of the organization.

For additional Resources, check out these websites:

Prepare. Reinforce. Go Further.

TCG Compliance Solutions is ready to assist you implement and enhance effective controls and best practices for seamless compliance.

Contact us for the necessary tools, resources and expertise to reach compliance efficiency.

Disciplinary Policy – Setting Clear Expectations

“No horse gets anywhere until he is harnessed. No stream or gas drives anything until it is confined. No Niagara is ever turned into light and power until it is tunneled. No life ever grows great until it is focused, dedicated, disciplined.” – Harry Emerson Fosdick

An effective compliance program should include well-publicized disciplinary guidelines that are applied consistently without regard to position or length of service. These guidelines should address non-compliance with the organizations Standards of Conduct, policies, and applicable statutes and regulations.

Disciplinary actions should be designed to prevent recurrences of the acts, deter others from similar conduct and maintain the integrity of the program. Transparency in guidelines and fairness in enforcement will help managers and employees understand the requirements and how they are to be used.

“The OIG believes that corporate officers, managers, supervisors, clinical staff, and other health care professionals should be held accountable for failing to comply with, or for the foreseeable failure of their subordinates to adhere to, the applicable standards, laws, and procedures.“

The phrase “foreseeable failure of their subordinates” places an additional burden on the leadership of the organization to prove that appropriate safeguards to prevent non-compliance are in place. Additionally, the OIG states “Managers and supervisors should be made aware that they have a responsibility to discipline employees in an appropriate and consistent manner.” Once again, leadership is held to a high standard.

If you are in a leadership role, this may seem overwhelming. Just remember, protection for leadership is provided when an organization has an effective compliance program that includes consistent disciplinary policies and actions. It doesn’t eliminate all risk, but it certainly provides a much higher level of comfort that risks are mitigated to the greatest extent possible.

For additional resources, check out these websites:

Prepare. Reinforce. Go Further.

TCG Compliance Solutions is ready to assist you implement and enhance effective controls and best practices for seamless compliance.

Contact us for the necessary tools, resources and expertise to reach compliance efficiency.

Managing Your Compliance Hotline

Once the compliance hotline is working, it is important to have a plan for managing the calls. Consistency is important, both in taking calls and responding to calls.

When developing your plan, take the following elements into account:

  • Ensure that your workforce, including contractors, are aware of hotline and its purpose
  • Track and manage all reports whether via hotline or an alternative means
  • Consistently manage investigations
  • Use data to evaluate and improve compliance

Click here for a more detailed Checklist.

In addition to well-developed protocols, consider the following recommendations from the OIG:

  • “Matters reported through the hotline or other communication sources that suggest substantial violations of compliance policies, Federal health care program requirements, regulations, or statutes should be documented and investigated promptly to determine their veracity. A log should be maintained by the compliance officer that records such calls, including the nature of any investigation and its results.”
  • “In addition to methods of communication used by current employees, an effective employee exit interview program could be designed to solicit information from departing employees regarding potential misconduct and suspected violations of policy and procedures.”

For additional resources, check out these websites:

Prepare. Reinforce. Go Further.

TCG Compliance Solutions is ready to assist you implement and enhance effective controls and best practices for seamless compliance.

Contact us for the necessary tools, resources and expertise to reach compliance efficiency.

ADRs – Do It Right The First Time!

The Office of Medicare Hearings and Appeals (OMHA) announced in January that it is suspending the assignment of most new requests for an Administrative Law Judge (ALJ) hearing because it has “been unable to keep pace with the exponential growth in requests for hearings.”  It does not expect to resume assignments of appeals by providers for at least 24 months with post-assignment hearing wait times continuing to exceed six months. This means that home health agencies and hospices that file for an ALJ hearing in February 2014 should anticipate that the hearing will be held no sooner than July 2016.

This new decision ups the ante for submitting strong ADR responses in a timely fashion.  TCG can help by providing expert reviewers to prepare responses and provide feedback on whether there may be additional documentation that would better support your response.

TCG’s experts are available:

  • As supplemental staffing to burst through a peak period of ADRs
  • On an ongoing basis to free up your staff to focus on day-to-day operations

See what TCG’s ongoing ADR Review clients are saying:

  •  “We appreciate all your help.  Our last 3 home health ADRs pulled regarding the PT probe edits have passed and been paid.  Your recommendation and assistance has been so beneficial!”
  •  “Your help with our F2F ADRs has been invaluable.  Not only are we getting paid, we have followed your advice on how to improve our process and physician education and the number of ADRs we are getting is declining.”

Click here for more information

One of the top reasons for Palmetto GBA denials in the fourth quarter of 2013 (11%) was that providers did not submit requested documentation in the required time frame.

TIP To prevent this:

  1. Monitor claims status on Direct Data Entry (DDE) for status/location SB6001
  2. Promptly submit records for each individual claim with a copy of the ADR request
  3. Include a document making a strong case for appropriateness of service
  4. Return to the address on the ADR within 30 days of the ADR date

Check out TCG’s self-help resources:

William C. Musick, BS, MBA, CHC

Mr. Musick is a Senior Associate and Project Manager with The Corridor Group and has over 20 years of experience in health care operations management, financial and systems analysis and project management. He is a licensed consultant with the Standards for Excellence Institute and is also certified by the Compliance Certification Board in Healthcare Compliance (CHC). Bill is an expert in feasibility analysis for the development of hospice and end-of-life care services, facility planning and development, strategic planning and financial risk/benefit analysis. He also works with chief executives and boards of directors to achieve new levels of effectiveness in the governance of public benefit organizations. Bill has a special interest in supporting home health and hospice providers develop and sustain a culture of compliance.

 

What’s New for Home Health and Hospice

The HHS Office of the Inspector General released its 2014 Work Plan on January 31, 2014. The plan has some changes and also continues some areas of focus from prior years. There was a net decrease in the number of topics specific to both Home Health and Hospice.

One new item was added under Medicare Hospices: the OIG will review the characteristics (length of stay, levels of care and common terminal illnesses) of hospice services provided to Medicare beneficiaries who reside in assisted living facilities (ALFs). This review was triggered by a MedPAC recommendation that the long length of stay for ALF residents bears further investigation

The following five topics were continued from 2013:

  • Medicare HHAs: Employment of Home Health Aides With Criminal Convictions
  • Medicare HHAs: Home Health Prospective Payment System Requirements
  • Medicaid HHAs: Home Health Services—Screenings of Health Care Workers
  • Medicaid HHAs: Home Health Services—Provider Compliance and Beneficiary Eligibility
  • Medicare Hospices: General Inpatient Care

Ten items that have been included in the 2013 plan were dropped for 2014:

  • Medicare HHAs: Home Health Face-to-Face Requirement
  • Medicare HHAs: Missing or Incorrect Patient Outcome and Assessment Data
  • Medicare HHAs: States’ Survey and Certification: Timeliness, Outcomes, Follow-up, and Medicare Oversight
  • Medicare HHAs: Medicare Administrative Contractors’ Oversight of Claims
  • Medicare HHAs: Trends in Revenues and Expenses
  • Medicaid Home Health Services: Duplicate Payments by Medicare and Medicaid
  • Medicaid Home Health Services: Homebound Requirements
  • Medicare Hospice/Hospitals: Acute-Care Inpatient Transfers to Inpatient Hospice Care
  • Medicare Hospices: Marketing Practices and Financial Relationships with Nursing Facilities
  • Medicare Hospices: Compliance With Reimbursement Requirements

Of potential interest is a new topic in the section entitled State Program Integrity Activities and Compliance with Federal Requirements. This review will focus on ensuring that states suspend Medicaid payments during a period when there is a credible allegation of fraud.

For in-depth information on the 2014 OIG Work Plan, check out these resources:

Health Care Compliance Association’s 2014 OIG Work Plan Series – Part 3: Home Health/Hospice
Presenter: Bill Musick, CHC, Senior Associate/Consulting Services Project Manager, The Corridor Group
February 28, 2014 |10 am PT |12 pm CT|1 pm ET| 1 pm ET |90 min.|1.2 CCB CEUs

Be prepared for the year ahead by taking advantage of the HCCA’s presentation of the 2014 OIG Work Plan for Home Health/Hospice. Our outstanding speaker will provide a serious, in-depth look at the OIG’s key compliance concerns for fiscal year 2014. If you’re looking for OIG Work Plan coverage that is substantial and to the point, don’t miss this conference.
*Subject to change depending on length of web conference content|

Learn more & register now

OIG 2014 Work Plan: Implications for Home Health and Hospice
Presenter: Janice Anderson, BSN, JD
March 31, 2014 | 10 am PT | 12 pm CT | 1 pm ET | 60 min. | 1 CEU

Learn more & register now

For additional Resources, check out these websites:

Full HHS OIG Work Plan for FY2014

Full HHS OIG Work Plan FY2013 

OIG Strategic Plan 2014 – 2018

Prepare. Reinforce. Go Further.

TCG Compliance Solutions is ready to assist you implement and enhance effective controls and best practices for seamless compliance.

Contact us for the necessary tools, resources and expertise to reach compliance efficiency.

Is Your Compliance Hotline Ringing Often Enough?

“A good many things go around in the dark besides Santa Claus.” -Herbert Hoover

“The truth will set you free, but first it will make you miserable.” – James A. Garfield

The OIG recommends that organizations have a well-publicized compliance hotline to provide a way for employees and contractors to easily report concerns without fear of retaliation. Confidential hotlines alert your organization to concerns about safety, security, discrimination, harassment, fraud, theft, and policy or code violations. If you do not know it is a problem, you cannot work to correct it.

Hotlines may be managed by your organization or by an outside vendor. It may operate via live operator, automated services, online portals, or a combination. Choose the best methods to reach your workforce.

However your hotline functions, there are two primary goals:

  1. One goal is to protect the anonymity of the reporter to the extent possible.
  2. The other is to have protocols that will encourage reporters to call back. The hotline is a way for you to dialogue with your employees on the following topics:
  • You may need additional information in order to conduct an investigation and need the opportunity to ask follow-up questions.
  • Callers may not be aware of the outcome of the investigation and may feel that their concern was not addressed. If they call back, you are able to assure them that their report was investigated and that appropriate action was taken.
  • Many calls may only require education. You may need to assure the reporter that current activities are in line with laws, regulations, and organizational policies or you may need to provide education to all or part of your workforce on appropriate activities. Identifying these issues is a great way to develop your compliance education program.

An increase in reports to your compliance department might actually may be a positive indication that your compliance education efforts are working; that your employees and contractors are paying more attention to the compliant culture of your organization; and that they are trusting that the reporting process will make a difference. If you have a hotline and it isn’t ringing, it may be worthwhile to figure out why.

For additional resources, check out these websites:


Prepare. Reinforce. Go Further.

TCG Compliance Solutions is ready to assist you implement and enhance effective controls and best practices for seamless compliance.

Contact us for the necessary tools, resources and expertise to reach compliance efficiency.

CBWA: Compliance by Walking Around

“If you wait for people to come to you, you’ll only get small problems. You must go and find them. The big problems are where people don’t realize they have one in the first place.” – W. Edwards Deming

There has been much written about Management by Walking Around (MBWA) and the benefits to an organization that practices this style of communication. Getting away from your desk and speaking with individual employees allows a level of communication that would be impossible from behind closed doors. This is particularly true when it comes to questions about compliance. Employees are more likely to voice compliance concerns and questions when they have a non-threatening opportunity to directly ask a question.

The size of the organization and the nature of providing care “in the field” can be a barrier to communicating by “walking around”. However, Compliance by Walking Around (CBWA) can take on many forms. Consider the following ideas:

  • Provide in-person training and allow time afterwards for individual conversations.
  • Participate in office celebrations.
  • Be engaged and available whenever you have the opportunity to interact with employees.
  • Hold regularly scheduled “Ask Compliance” teleconferences-discuss questions that have been presented to the compliance office and allow ample time for additional questions from participants. This may be expanded to “Ask (your organization)” with involvement from clinical and operational leaders.

Keep in mind the following limitations of CBWA:

  • CBWA is more effective if it is consistently used and no just when there is a crisis.
  • Credibility can be damaged if there is no follow-up to concerns or questions-be sure there is a way to contact the employee who asks a question if you don’t have an immediate answer or need to provide further follow-up.
  • CBWA will only reach those individuals with whom the interactions occur-it does not replace other lines of communication.

For additional resources, check out these websites:

Prepare. Reinforce. Go Further.

TCG Compliance Solutions is ready to assist you implement and enhance effective controls and best practices for seamless compliance.

Contact us  for the necessary tools, resources and expertise to reach compliance efficiency.

Effective Lines of Communication

“The single biggest problem in communication is the illusion that it has taken place.” – William Butler Yeats

The OIG is clear in defining its expectations for effective communication, but are you sure that communication is occurring? Your Compliance Officer needs to be directly available to your employees. While following the “chain of command” is generally encouraged, when it comes to compliance, links in the chain can, and sometimes should, be skipped. Employees should feel comfortable contacting the Compliance Officer directly and should not fear retaliation.

Frequently employees seek out their direct supervisors with concerns or questions. Unfortunately, many supervisors feel ill-prepared to effectively respond to compliance questions. It is the role of the Compliance Officer to encourage open communication with supervisors, providing general talking points so that supervisors are providing correct and consistent information or knowing how to gather information and/or refer questions to more knowledgeable individuals in the organization so that questions can be promptly resolved.

Here are some steps you can take to facilitate effective communication:

  • Develop and distribute confidentiality and non-retaliation policies
  • Train supervisors how to be comfortable encouraging and handling compliance questions
  • Publicize contact information for the compliance office, including phone and email
  • Thank employees that contact the compliance office
  • Document all questions and responses to identify trends and evaluate the need for further education
  • If immediate answers cannot be provided, follow-up quickly
  • Ensure that employees asking questions understand the process that will be used to follow-up on questions, even if detailed results may not be appropriate to share

“At a minimum, comprehensive compliance programs should include the following: The creation and maintenance of a process, such as a hotline or other reporting system, to receive complaints and ensure effective lines of communication between the compliance officer and all employees, and the adoption of procedures to protect the anonymity of complainants and to protect whistleblowers from retaliation.”- OIG Compliance Guidance

For additional resources, check out these websites:

Prepare. Reinforce. Go Further.

TCG Compliance Solutions is ready to assist you implement and enhance effective controls and best practices for seamless compliance.

Contact us for the necessary tools, resources and expertise to reach compliance efficiency.

How Effective Is Your Compliance Training?

“The greatest thing in this world is not so much where we are, but in what direction we are moving.” – Oliver Wendell Holmes, Jr.

To Do List:

  • Training Program Developed
  • Training Program Implemented
  • Employee Completion Rate 100%

Not quite. How do you know if your message was effective? How do you measure effectiveness?

One helpful tool to assess training is the Kirkpatrick Four-Level Training Evaluation Model:

Level 1: Reaction
How did your employees react to the training?
Tip: Use training evaluation forms to help you determine the overall reaction.

Level 2: Learning
Did your employees learn the material?
Tip: Use pre- and post-tests to assess whether your learning objectives were achieved.

Level 3: Behavior
Your employees may react well to your training, and they may have learned your objectives, but have they changed their behavior?
Tip: An increase in calls to the compliance department is one way to show employees are thinking differently about their roles and responsibilities within the organization.

Level 4: Results
Effective compliance training will have measurable results.
Tip: Improved audit scores are one way to demonstrate positive change.

Provide your employees support, encouragement, and recognition to maintain positive momentum.

So – Finish up that to-do list:

  • Training Effectiveness Evaluated
  • Done!

For additional Resources, check out these websites:

Evaluating Training Programs

Prepare. Reinforce. Go Further.

TCG Compliance Solutions is ready to assist you implement and enhance effective controls and best practices for seamless compliance.

Contact us for the necessary tools, resources and expertise to reach compliance efficiency.

Employee Engagement: Win-Win

“Education is not the filling of a pail, but the lighting of a fire.”

– William Butler Yeats

Developing a sustainable culture of compliant and ethical behavior begins by inspiring your employees to succeed. An effective program will help employees connect the dots between compliance training, compliant behavior, and personal success. It will also help them understand the potential consequences of failure in these areas.

Use real world examples to help your employees understand the importance of a regulation, such as maintaining privacy. It may not be meaningful to hear that a hospital nurse was fired for looking at a Hollywood star’s medical record. Realistically, how often will your employees face that test? Instead use examples of mistakes that occurred as the result of careless behavior, not willful disregard.

  • A home health nurse commented to an assisted living employee that one of their former patients was adjusting well to the new facility. The family of the resident had not wanted the previous organization to know where their loved one had been moved. They filed a privacy violation complaint with the nurse’s employer, the Board of Nursing, and the Office for Civil Rights. All three organizations conducted independent investigations.
  • A hospice social worker left patient information visible on the front seat of her vehicle while she was grocery shopping. Someone in the parking lot saw the information, knew the patient, and notified the patient’s family. A complaint was filed with the employer.

These examples help employees see that individual behavior has individual consequences. A benefit to the organization is that employees who protect themselves through compliant behavior also protect the patients and the organization.

Win-Win!

For additional resources, check out these websites:

Prepare. Reinforce. Go Further.

TCG Compliance Solutions is ready to assist you implement and enhance effective controls and best practices for seamless compliance.

Contact us for the necessary tools, resources and expertise to reach compliance efficiency.

Training the Multi-Generational Workforce

“Managing multigenerational workforces is an art in itself. Young workers want to make a quick impact, the middle generation needs to believe in the mission, and older employees don’t like ambivalence. Your move.” 

 – Working Knowledge Newsletter, Harvard Business School – April 17, 2006

Studies tell us that different generations have different learning styles, so how do you provide training that is engaging and doesn’t leave half of the audience updating their Facebook status and the other half pondering their schedule for the rest of the day?

With all generalizations, it is important to be aware of the different learning styles when developing your training programs.

Baby Boomers (1946-1964) want to know the credentials or expertise of the trainer. They are comfortable with email but may not have embraced other technologies. Personal interactions are their preferred method of communication.

Generation X (1965-1980) is comfortable with technology and will be the first to fact check and look you up on Google. They are independent and self-reliant and prefer technology-based training. They require frequent and specific feedback.

Millennials (1981-2000) have come to expect immediate responses to their texts and this expectation carries over into their work. They prefer flexibility in training and appreciate coaching/mentoring.

Present your message in multiple formats to reach all workers and quell allegations of ineffective communication. For quick updates, Baby Boomers prefer verbal communication while Generation X and Millennials like notification through email and instant messaging. Find the right combination for your workforce to match corporate goals with employee needs.

TIP: Recruit a training advisory task force with representatives from multiple generations to help you assess your training approaches.

For additional resources, check out this website:

Leading and Engaging Today’s Multi-Generational Workforce 

Prepare. Reinforce. Go Further.

TCG Compliance Solutions  is ready to assist you implement and enhance effective controls and best practices for seamless compliance.

Contact us for the necessary tools, resources and expertise to reach compliance efficiency.

Education and Training is Essential for an Effective Compliance Program

Compliance training is not typically described as “riveting” or “engaging.” As a result, long compliance training sessions are not always the best route to your desired goal. Providing your employees with relevant chunks of information on a frequent basis and repeating your message often will meet all adult learning styles. Newsletters, Tips, and Frequently Asked Questions (FAQs) are great ways to consistently spread your message. It can also be advantageous to piggyback compliance messages with other training sessions, for example during sales and marketing training or case conference/interdisciplinary team meetings.

The following are compliance training topics recommended by the HHS Office of Inspector General (OIG):

  • Federal and State statutes, regulations and guidelines
  • Policies and procedures of the organization
  • Policies of private payors
  • Ethics
  • Fraud and abuse laws
  • Federal health care program requirements
  • Patient rights
  • Marketing practices
  • Code of Conduct
  • Conditions of Participation
  • Referral inducement
  • Clinical record alterations

Your compliance training sessions are strongest if they are delivered or explicitly endorsed by a senior level manager or a respected compliance professional within your organization or field.

Also consider the following OIG comment in their Compliance Guidance: Where feasible, the OIG recommends that a [provider] afford outside contractors the opportunity to participate in the [provider's] compliance training and educational programs, or develop their own programs that complement the [provider's] code of conduct, compliance requirements, and other rules and practices.

For additional Resources, check out these websites:

OIG Compliance Program, Guidance for Hospices 

OIG Compliance Program, Guidance for Home Health Agencies

Prepare. Reinforce. Go Further.

TCG Compliance Solutions  is ready to assist you implement and enhance effective controls and best practices for seamless compliance.

Contact us  for the necessary tools, resources and expertise to reach compliance efficiency.

Empowering Your Compliance Officer

“Coming together is a beginning; keeping together is progress; working together is success.” – Henry Ford

The role of the compliance officer is to develop and oversee the organization’s compliance program. In order for the compliance officer to be successful, they will need the following:

  • Support from the top
  • Autonomy – reporting to the CEO and unfiltered access to the Board of Directors
  • Appropriate authority to carry out duties
  • Sufficient personnel for the size of the organization
  • Sufficient financial resources to manage the program

It is also helpful for the compliance officer to have a “seat at the table” during any meeting where important business decisions are being made.

Encourage your compliance officer to obtain specific training and certification in health care compliance and/or privacy compliance. Gaining a higher level of expertise instills confidence all around.

For additional resources, check out these websites:

Prepare. Reinforce. Go Further.

TCG Compliance Solutions is ready to assist you implement and enhance effective controls and best practices for seamless compliance.

Contact us  for the necessary tools, resources and expertise to reach compliance efficiency.

Due Diligence

Health Care Reform is creating one of the most active consolidation markets in decades. In addition to complex business considerations, managing or facilitating a merger, acquisition, strategic alliance or partnership can be challenging on many fronts. A thorough due diligence evaluation is essential to meet your objectives.

Consider these following due diligence tips:

  • Have a clear goal and set of evaluation criteria. Build a strong transaction team with a mix of internal personnel and external advisors to provide objective guidance and varied experience.
  • Perform a quick probe of clinical documentation compliance to support payment before committing other due diligence resources.
  • If indicated by this probe, then conduct more comprehensive due diligence to validate the investment opportunity and to identify any potential risk factors. Consider all factors: management, financial, clinical, regulatory, environmental, and legal.
  • Using due diligence findings, accurately estimate post-transaction investment requirements that will be needed to meet your objectives. Typical needs include: recruiting talent, improving technology, documentation training, and ongoing staff development.
  • Establish a robust integration plan that takes into account whether and how you will transform the business in light of new care delivery models.

Evaluate Your Rehospitalization and Care Transitions Know-How

Since October 1, 2012, the Hospital Readmission Reduction Program (HRRP) that penalizes hospitals with high readmission rates for certain conditions within 30 days of discharge has been in effect. For the first two years, acute myocardial infarction, pneumonia and heart failure will be the only applicable conditions on which readmission rates will be calculated. Beginning in 2015, however, CMS will add additional conditions or procedures it believes represent high costs and high volumes of readmission.

As post-acute providers, you have a vital role in ensuring appropriate care transitions to and from acute care settings.

Track and Measure Key Metrics.

  • Use key metrics to show your acute care partners that your organization is at or above industry standards, such as: Patient outcomes related to hospital admissions and ED visits, and HH-CAHPS scores.
  • Establish other measures and value points that demonstrate your success as a solution partner.

Establish and Monitor Your Care Transition Best Practice Model.

  • Promote specialty programs that show evidence of success in reducing unnecessary re-hospitalizations and improving coordination across care settings.
  • If your organization does not have such programs, identify what programs would be of most value to your local health system; collaborate with teams from the hospital, nursing homes and physicians to develop and implement a transitions of care program to assist the health system reduce re-hospitalizations.
  • Prepare to cover the cost of non-reimbursable services.

Reserve a Seat at the Table.

  • Ensure your team has the knowledge and resources to ‘sit at the table’ with an ACO or health system.
  • Ask to have a seat at the table and be prepared to demonstrate why your organization should be part of their solution.

Downloads/Links

Are you HRRP Ready? Embrace Your Unique Position.

The October 1st implementation of the Hospital Readmissions Reduction Program (HRRP) is quickly approaching and for the best outcome, home care and hospice organizations need to be fully prepared. It is important that providers embrace their unique position in the care continuum to ensure appropriate care transitions. Leading providers are instituting interdisciplinary team assessments, interventions, and care coordination across the continuum of care (e.g., Acute, Skilled Nursing, Home Care and Hospice) by reviewing rehospitalizations and Emergency Department visits on a regular basis. Most importantly, they have integrated a quality focus process and outcome measurements to track patient care.  Is your organization ready for the HRRP challenge? Learn more by reading TCG QuickTips©: Care Transitions Collaboration—Your Role in Reducing Avoidable Rehospitalization or contact a TCG Consulting Services expert.

Are you ready for the HRRP kick-off? Strategic Partner Relationships Count.

With the October 1st “kick-off” to the Hospital Readmissions Reduction Program (HRRP), providers across the care continuum will begin to see the impact of certain hospital readmissions within 30 days of discharge. Home care and hospice providers play a vital role in ensuring appropriate care transitions under health care reform. Savvy providers are identifying key strategic referral and care coordination partners who demonstrate performance strength and value in the care continuum. Most importantly, they are solidifying relationships with partners who can assist in the development and integration of a comprehensive approach and build upon their hospital and referral strategy. Does your organization have a plan to get in front of C-suite executives who are making partnering decisions for appropriate care transitions? Learn more by reading TCG QuickTips©: Care Transitions Collaboration—Your Role in Reducing Avoidable Rehospitalization or contact a TCG Consulting Services expert here.

Care Transitions Collaboration – Your Role in Reducing Avoidable Rehospitalization

On October 1, 2012, the Hospital Readmissions Reduction Program (HRRP) will become effective as part of the March 2010 Patient Protection and Affordable Care Act (PPACA). This program requires the Center for Medicare and Medicaid Services (CMS) to reduce payments to hospitals with excess readmissions for unnecessary readmissions within 30 days of discharge if the patient has acute myocardial infarction (AMI), pneumonia (PN) and heart failure (HF). CMS views three stages related to readmissions:

  • Inpatient care processes
  • Effective discharge (soon to be termed transitional level planning)
  • Post discharge or transitional care

This is just another step the Federal Government and CMS are taking to appropriately manage a patient’s care and the associated cost across the care continuum.

In the new era of Healthcare Reform, home care and hospice leaders play a vital role to ensure the appropriateness of care, in the right setting.

Solidify Strategic Partner Relationships.

  • Identify key strategic referral and care coordination partners who demonstrate performance strength and value in the care continuum.
  • Solidify relationships with physicians who are aligned with the hospitals you serve.
  • Align with strategic “partners” (e.g., hospitals, subacute facilities, therapy organizations, physicians, consultants, pharmacy providers, software vendors, medical supply companies, etc.) who can assist in the development and integration of a comprehensive approach, including clinical, operational and financial performance.
  • Build upon your hospital and referral strategy. Have a plan to get in front of C-suite executives who are making partnering decisions now.

Create Your Best Practice Model for Collaboration and Coordination of Care.

  • Develop a best practice approach to disease state management to support ACOs, hospitals, physicians, payers and community-based providers who will be sharing the risk for payment.
  • Track and monitor outcomes for continuous improvement of your hospital transfer/readmissions rates by top diagnosis. Have this data readily available when meeting with key referral sources.
  • Align care delivery protocols to complement hospitals and physicians in the care continuum.

Embrace Your Unique Position to Ensure Appropriate Care Transitions.

  • Implement OASIS + holistic assessments (e.g., depression, health literacy, rehospitalization risks, etc).
  • Implement consistent identification of signs and symptoms that may lead to hospitalization and identify ongoing disease and symptom management protocols.
  • Institute interdisciplinary team assessments, interventions, and care coordination across the continuum of care (e.g., Acute, Skilled Nursing, Home Care and Hospice). Review rehospitalizations and Emergency Department visits at weekly team meeting.
  • Invest in technology that can assist in seamless review of data in order to showcase ongoing quality focus process and outcome measures.

Downloads/Links

Lead or Be Led

“We cannot predict the future. But we can create it.” – Jim Collins

As we consider the continual changes that surround us–in the world, in our country, and in home care and hospice–no one could have predicted how these events could alter our way of thinking and leading. Some have chosen to lead through the unknown. Others will take a “wait and see” attitude and be led.

Leading organizations reject the idea that forces outside their control determine their success. They accept full responsibility for their own fate and take action.

Develop a plan and create discipline surrounding its execution.

  • In times of chaos, leading organizations have a specific, methodological, and consistent (SMaC) plan. The more uncertain your environment, the more SMaC you need to be.
  • Plan and rapidly implement. An average plan that is executed can be better than a brilliant plan that never comes to life.

Reinvent partner and referral source relationships.

  • Identify partners with whom you can collaborate across the post–acute continuum and successfully prevent readmissions.
  • Build upon your hospital strategy. Have a plan to get in front of the C–suite where partnering decisions are being made now.
  • Solidify relationships with physicians who are aligned with the hospitals or with partner hospitals on your radar.

Invest in a solid technology roadmap and data analysis.

  • Ensure your organization has outcomes data you can trust that provides insight regarding costs, especially for the top three conditions targeted for hospital readmission penalties beginning 2012 (CHF, pneumonia, and AMI).
  • Have data–driven proof of your outcomes for cost, quality, and readmissions analyses.

Create an agile business model to meet the care continuum for the 21st century.

  • Know the changing paradigms, such as, Enterprise Care Management vs. Silos; Coordination of Care vs. Episodes; Transition of Care vs. Discharge; Keeping People Well vs. Caring for the Sick.
  • Prepare to transition from volume–based to value–based care.
  • Have a mindset of continuous improvement to realize greater efficiency and quality.
  • Identify industry experts you can trust for guidance.

Downloads/Links

Successful Positioning for Industry Consolidation

Future scenarios for home care and hospice point to consolidation as a key element across all healthcare sectors. Providers need to be ready for some form of affiliation. Whether you hope to be the consolidator or expect to be consolidated, it’s important to know and understand how an organization can best prepare itself to become an attractive partner of other entities.

Envision your organization’s position in the future of healthcare delivery.

  • Do you already own a major share of a niche or major service line at a local or regional level?
  • Do you have solid relationships with major health systems, free-standing hospitals, health plans, physician groups, and/or long-term care and senior living communities?
    • If so, will those relationships be sufficient to ensure that you are a key player in affiliations that will shape the future of healthcare?
    • If not, is selling or merging your best option to reach critical market share?
  • Do you have the ability to be the consolidator or is your best option to consolidate with one or more other organizations?
  • What is a realistic target role and position for your organization?

Assess your organization’s strengths and value proposition to take advantage of opportunities.

  • Culture and leadership team bench strength
  • Clinical expertise and patient care services, including Home Health Compare, QAPI outcomes and data demonstrating strength of care delivery
  • Effective cost structure with respect to projected reimbursement, including productivity and models of care
  • Compliance with Medicare CoPs (low risk of condition or standard-level deficiencies under survey)
  • Compliance with reimbursement requirements (low risk of recoupment under ADR or government audit)
  • Information technology capacity for clinical and business management

Invest in initiatives that will address weaknesses and improve your value proposition.

  • Infrastructure investments, especially in human capital and technology
  • Corrective actions to improve compliance with Medicare CoPs and reimbursement requirements
  • Staff recruitment, training and retention
  • Business development activities
  • Optimal contractual obligations to employees and vendors

Prepare for a comprehensive organizational review and be prepared with answers before questions are asked.

  • Ready a comprehensive prospectus containing company-wide and supporting data that a potential buyer or partner will want to evaluate
  • Organize source documents to support the prospectus
  • Identify key contact person and team who would be involved in the process
  • Know your value

If you want to sell, work with an experienced broker who can who can provide professional advice to maximize your organization’s value and/or goals.

 

Downloads/Links

Working Smarter, Not Harder

As home care and hospice have become ever more complex, volatile and demanding, several key ideas can help make the difference between feeling overwhelmed and thriving. Use these tips to help your organization operate at peak effectiveness.

Maximize your existing resources.

  • Engage your employees and volunteers in order to increase enthusiasm and commitment to improving outcomes:
    • Interact with staff and volunteers regularly and foster their engagement by connecting their work to the difference it makes for patients, families, co-workers and the community
    • Ask what is going well, what needs improvement, and how you can help them be successful
  • Leverage existing tools, computer applications and vendors:
    • Ensure tools are kept up-to-date and that you have upgraded software to the most recent version
    • Assess whether there are modules you aren’t using that could improve efficiency or effectiveness
    • Enlist your vendors to help you address the key issues – those 20% of problems that cause 80% of the headaches
  • Invest in coaching skills for your managers and supervisors so that they can help tap and build employees’ passion for doing a good job

Simplify processes.

  • Make things simple for front-line workers, as opposed to management or corporate support functions
  • Enlist your engaged employees and vendors (see previous section) to ensure that information, tools, and processes support efficiency and quality
  • Use the TCG Simplification Checklist to assess key processes

Increase workforce flexibility.

  • Extend work hours beyond the traditional 8am to 5pm work day – institute afternoon and evening shifts which optimize coverage when patients and referral sources want it
  • Extend the work week by including weekend days in a “normal” work week
  • Check whether your task assignments are overly RN-centric – ask what tasks your RNs are doing that could be performed equally well by other team members

Downloads/Links

Positioning for Success

Recognizing emerging trends, let alone being at the leading edge, can be daunting to even the most experienced leader in today’s health care environment. Identifying the trends, determining which are key to your organization’s future, and deciding whether and how you should respond – are critical questions as you plan for future success in a rapidly evolving environment.

Here are some tips on how to identify and stay on top of trends that are shaping healthcare, and how to determine what your response will be.

Talk.

  • Ask your leadership team and your board what success will look like in 2020 for your organization given the trends you’ve identified and the likely changes in your strategic environment.
  • Ask your colleagues, locally and nationally, what strategies they are implementing and why.
  • Meet with leadership of health systems, hospitals, and physician groups; take responsibility for leading robust discussions to develop initiatives that will be beneficial for all those involved in the conversation.

Look and Listen.

  • Stay abreast of new healthcare models (ACO, TCM, CCM, AIM, etc); which will be the best strategic fit(s) with your organizational culture, your service area, and your population base.
  • Include all staff in the conversation to help define approaches and best practices with respect to emerging models.
  • Develop business plans that take advantage of key trends and reduce potential risks.

Read.

  • See below for key strategies that leading-edge home care and hospice providers are focusing on in response to emerging healthcare trends.
  • See TCG’s recommended reading list for how to position your organization for success.

Execute.

  • Experiment now with pilot programs–don’t wait for someone to tell you what you must do.
  • Don’t become paralyzed by the risks or uncertainties, but add resources, contingency plans, and exit criteria to mitigate them.
  • Try, and try again; no one is yet an expert in these new models – it could be your organization who is the trend-setter.

Downloads/Links

Leadership

Visionary leadership is the key to success or failure. Yesterday’s solutions and strategies may not work for today’s challenges. Practical tips for home care and hospice leaders to think and act differently in 2012 and beyond.

  • Leadership at the executive level alone is not enough. It is not just a cliché that people are your most valued resource. Invest in and cultivate the diverse talent you have. Energize leadership qualities up, down and across your organization.
  • Adopt a “beginners mind.” Be curious. Ask questions, listen and be open to possibilities. Don’t accept the first idea as the answer. Always look for more and don’t assume it can’t be done! Notice the obvious.
  • Change before you have to. Focus on what you can do to help things go right, rather than correcting them when they go wrong. Focus not on what others should be doing, but on what you can do to help them.
  • Harness the power of progress. Despite the fact that most managers believe that employees are motivated by recognition, recent studies show that the top motivator is progress—whether real or perceived. Set clear and achievable goals. Provide resources and encouragement. Celebrate progress and make it visible.

Downloads/Links

Financial Performance

Financial success today means thinking beyond cutting costs. To thrive, organizations must work intentionally to implement a range of integrated actions in a systematic, disciplined way to achieve positive, sustainable fiscal results.

  • Ensure basic operational processes are functioning effectively. Efficient, cost-effective operational practices result in the right discipline, the right delivery mechanism, at the right time, for the best patient outcomes. Effective hiring, scheduling, case management, productivity, technology deployment, staff development and back office functions must be in place.
  • Create a culture of performance excellence and accountability. Leadership’s capacity to model accountability and execute a plan to achieve performance goals is critical to take an organization to the next level. All employees need to perform at or above expectations. When employees underperform, the costs are significant: additional staff to compensate for poor performers, inefficiencies in work processes, lowered morale or turnover of high performers.
  • Reduce the number of part-time employees. Employees who work less than forty hours per week are typically the most expensive employees in the organization. Part-timers may be less productive, require the same supervision, and their employment costs (recruitment, training and benefits) are proportionately more than for full time staff. Consider a ratio of 75:25 full-time to part-time or per diem staff to improve your bottom line.
  • Change up your work week. Patients need to be seen and visiting staff/referral sources need to be supported seven days a week, not just on Monday through Friday. Design your work week to include at least one Saturday or Sunday (e.g., Wednesday – Sunday, Thursday – Monday, Friday – Tuesday, Saturday – Wednesday, or Sunday – Thursday). Change the work week schedules for both visiting and administrative employees. The revised schedules will reduce overtime and the need to hire additional staff for weekends.

Downloads/Links

Ensuring Continuity of Executive Leadership

It’s never too soon to plan for transition in executive leadership. To expand on a quote from Benjamin Franklin, “Nothing is certain but death and taxes”…and executive transition. Whether planned or unplanned, an organization that has established policies and processes will ensure a smooth continuity of executive leadership. Although continuity of executive leadership, frequently referred to as “succession planning,” most often focuses on the chief executive, organizations would do well to consider how these tips apply to other executive staff and key board members as well.

  • Build trust between board and chief executive and between chief executive and his/her executive team to allow for robust discussion of potential transitions and leadership development needs on an ongoing basis. Recognize that a number of barriers can prevent this from happening.
  • Replace reliance on individuals with reliance on systems. Develop policies to respond to planned and unplanned vacancies and create systems to ensure that important information and contacts are systematically recorded and monitored rather than kept “in someone’s head.”
  • Develop a system for identifying needed skills and personal attributes for executives, assess performance regularly and plan for opportunities to build leadership bench strength. Integrate career planning discussions into the performance evaluation process so that intentions and desires are clear and not assumed.
  • Begin the planning for a permanent transition by confirming the core essence of the organization – its vision and values – and then tailor your search to a current strategic direction. Selecting an executive for your organization is one of the most important tasks in ensuring its long-term success. Start with a firm foundation by confirming the context in which your next leader will be operating so that you can select the best person possible to lead within that context. Recognize that the skills that have led to success in the past may not be the skills most important for the future.
  • Move quickly, but methodically, when there is a hint of an upcoming vacancy. Today’s reality is that external searches can take six to nine months. Being able to immediately implement a pre-existing plan will give you a jump start, but expect that a thorough and successful process will take time, energy and resources.
  • Assess your readiness for executive transition.

Downloads/Links

Reinforcing a Culture of Compliance

Compliance is an increasingly critical element of home care and hospice programs. Good leaders recognize that training and formal compliance plans are only as strong as the culture in which they exist. These three tips will help you ensure that your organization’s culture supports compliance with state and federal regulations.

  • Set a strong compliance example at the board and senior leadership levels.
    • Demonstrate through actions and attitudes that regulatory compliance is a top priority.
    • Demystify how the organization deals with compliance lapses by responding in an open and forthright manner.
    • Encourage the reporting of “bad” news sooner rather than later by exhibiting an openness to learning from failures or mistakes.
  • Provide opportunities for learning and discussing compliance expectations.
    • Interweave ethics and compliance training into all training and relate it to everyday issues.
    • Focus training on how to deal with situations with increased potential for compliance problems.
    • Use lapses as learning opportunities. Convene crossfunctional teams to determine what can be done to educate staff in order to increase awareness of the issue and prevent reoccurrence.
  • Understand your organization’s current culture by assessing it regularly using questions such as these:
    • If you were to observe what you think is a clear compliance issue, are you confident that you know what to do?
    • In the last three months, how frequently have you observed compliance lapses?
    • During the last three months, how frequently have you observed open discussion of gray areas related to compliance?

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