New OIG Advisory Opinion on Provision of Items and Services Below Cost or Free of Charge to Referral Sources in Exchange for Referrals

In an Advisory Opinion posted on August 4, 2011, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services concluded that the provision of items and services below cost or free of charge to referral sources likely violates the federal anti-kickback statute.  A home medical equipment (HME) company requested the Advisory Opinion. More »

Key Steps in a Home Health Agency Start up Process

In our previous article, we explored the important decisions one needs to make when entering the home health and hospice marketplace, whether to start-up a new agency or purchase one already in business. Perhaps, after looking at the home health or hospice agencies available in your community, you have decided to start your agency from scratch. Today, I explore the anatomy of an agency start-up, and the key steps involved in the start-up process. Finally, I offer tips you can use to ensure success in your new business venture. More »

To Purchase or Start-Up a New Home Health Agency: How Do You Decide?

Are you new to the home health and hospice marketplace? With the aging demographics of the American population, there is increased interest in home health and hospice agencies as viable business opportunities. If you have made the decision to enter the home health or hospice marketplace, the next, most important decision to make is whether to start up your agency or purchase one already in business. There are advantages and disadvantages to either choice. Today, I provide some guidelines to help you make a decision that is right for you. More »

Part 6: Accountable Care Organizations (ACO’s) - Patients’ Right to Freedom of Choice of Providers

Patients who are assigned or "aligned" with physicians who participate in ACOs are not required to receive services from such physicians or from any other participants in ACOs. More »

Part 5: Accountable Care Organizations (ACO’s) - Can Post-Acute Providers Participate in ACOs?

ACOs seem to be the next "big thing."  Doctors and hospitals clearly have a role to play in ACOs.  Many post-acute providers, however; including home health agencies, hospices, and HME companies; would like to know if they can also be part of ACOs. More »

Part 4: Accountable Care Organizations (ACO's) - Why Hospitals Need Post-Acute Providers

As indicated above, ACO's will share in cost savings if they meet performance standards for both quality of care and cost savings.  Specifically, there are thirty-three required quality measures for use in establishing performance standards that ACO's must meet in order to share in savings for at least the first year of three years.  More »

Part 3: Accountable Care Organizations (ACO's) - Final Regulations Issued

Final regulations have now been released and will be published in the Federal Register soon.  The first agreements with ACO's will take effect on April 1, 2012.  The final regulations generally provide as follows: More »

Part 2: Accountable Care Organizations (ACO’s) - What Post-Acute Providers Should Do Now

Proposed regulations to implement these provisions were published in the Federal Register on April 7, 2011.  Comments regarding the proposed regulations must be received by the Centers for Medicare and Medicaid Services (CMS) no later than sixty days after the date of publication. More »

Part 1: Accountable Care Organizations (ACO’s) - Proposed Regulations

Section 302 of the Affordable Care Act (ACA) includes provisions related to Medicare payments to providers of services and suppliers that participate in Accountable Care Organizations (ACO's).  Providers of services and suppliers who participate in ACO's will continue to receive payments under Parts A and B of the Medicare Program, but will also be eligible for additional payments if they meet certain requirements related to quality of care and cost savings.  The Secretary of the U.S. Department of Health and Human Services is required to establish ACO's no later then January 1, 2012. More »

Post-Acute Providers That Pay to Participate in Discharge Planning Systems Likely Violate the Anti-Kickback Statute

On May 20, 2011, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services, the primary enforcer of fraud and abuse prohibitions, posted Advisory Opinion 11-06.  This Opinion makes it clear that post-acute providers that pay hospitals to participate in e-discharge planning systems likely violate the federal anti-kickback statute.  Hospitals utilizing such systems that require post-acute providers to "pay to play" also likely violate the federal anti-kickback statute. More »

Important Rulings on Hospice Caps from Courts in Texas and Oklahoma

On January 6, 2011, a federal district Court in Texas ruled that the federal regulation that established how to calculate the cap on Medicare benefits payable to hospices annually directly conflicts with the statute it implements. [Harris Hospice, Inc. v. Sebelius, Nos. 4:10cv252, 4:10cv275 (E.D. Tex.)]  The Court also ruled that the Secretary of the U.S. Department of Health and Human Services (HHS) cannot overrule the Provider Reimbursement Board’s (PRRB’s) grant of expedited judicial review. More »

Face-to-Face Encounters by Medical Directors

Effective April 1, 2011, providers may not be paid for services rendered if patients have not had appropriate face-to-face encounters with physicians during required time periods. In order for home health agencies and hospices to be paid for services provided, documentation of these encounters must also meet applicable requirements. More »

Face-to-Face Encounters: Avoiding Liability for Abandonment

Providers are at risk for legal liability when they terminate services to patients. Termination of services has historically been warranted by the following circumstances, among others: violence or threatened violence, noncompliance by patients and/or primary caregivers, inability to provide adequate assistance, or inappropriateness for services. Providers are understandably concerned about the possibility of legal liability associated with the termination of beneficial services. More »

PART 1: Revised Standards of Practice for Case Management – Duty to Advocate

Standards governing the practice of case management were first published in 1995 by the Case Management Society of America (CMSA). The standards were revised for the first time in 2002, and again in 2010. This is the first in a series of articles about the legal and ethical implications of the standards revised this year. More »

PART 2: Revised Standards of Practice for Case Management – Ethics and Patients’ Right to Freedom of Choice of Providers

Standards governing the practice of case management were first published in 1995 by the Case Management Society of America (CMSA). The standards were revised for the first time in 2002 and again in 2010. This is the second in a series of articles about the legal and ethical implications of the standards revised this year. More »

Do Your Homework!
Due Diligence 101: Home Care and Hospice

The activities during the due diligence of a home health or hospice license – whether covering single or multiple locations – involves the examination of a number of components in order to assess the efficiency and compliance of an agency. We use a number of proprietary forms to guide the audits in areas such as clinical, regulatory, administrative and environmental considerations. Within each area are key indicators that the auditors use to measure the findings against industry requirements or best practice. More »

Peering Into an Invisible Window of Time

There is an invisible metric associated with death which has not been recognized by the healthcare industry. I cannot ever remember seeing this specific topic discussed in the professional literature. No national or regional data are kept on this subject matter and, therefore, no one even recognizes there are associated issues which need to be examined and corrected. More »

Part 1: Differentiate and Stand Out From The Rest!

In the summer edition of Insights, a publication of NHPCO’s National Council of Hospice and Palliative Professionals, three articles present some excellent ideas for hospice CEOs, administrators and owners/boards of directors to consider as they plan for a future which will likely bring changing reimbursement methodologies from Medicare and Medicaid, changing regulations, and changing numbers and types of competitors to the local community environment. More »

Part 2: Differentiate and Stand Out From The Rest!

In the September issue of this newsletter, we began our discussion of the concept of DIFFERENTIATION as a growth strategy. We defined it as those services and features that set apart an organization from its competition and talked about the common tendency to try to grow by imitating others rather than by developing a marketing plan around those elements of the organization that are special and important to the customer. More »

Part 1: Preparing for Audits - ZPIC Audits

The Centers for Medicare and Medicaid Services (CMS) are now conducting ZPIC audits. ZPIC’s are conducted by Zone Program Integrity Contractors. Unlike RAC audits that target identification of overpayment and CERT audits that attempt to pinpoint improper payments, ZPIC audits focus on fraud in the Medicare Program. This means that ZPIC contractors can audit the integrity of all Medicare claims, both pre- and post-payment. More »

Is He or Isn’t He Hospice Appropriate?

This is a more complex question than it seems. And it is really a two part question: “Is the patient hospice eligible?” And secondly “Is the patient hospice appropriate?” We are well advised not to confuse the two questions and to ask and answer the first question before pursing an answer to the second question. More »

The Cookie Lady is Dead!

For the past 22 years I’ve weathered Nor’easters in New England, Tropical storms in the Southeast, whiteouts in the Midwest, heat waves in the South and even earthquakes in the West. No, I’m not a meteorologist. I’m a sales coach and trainer specializing in hospice and homecare. I've experienced Mother Nature’s wrath obtaining various “goodies” while riding with sales reps so they can hand them out to their referral sources! More »

Why Discharge Planners/Case Managers Need to Know About Legal Implications of Provision of Free Services to Patients

Based upon their overriding commitment to patients, case managers or discharge planners may be tempted to “take up the slack” by urging post-acute providers to render free or voluntary services to patients. Case managers/discharge planners may state to post-acute providers that they will not receive additional referrals unless they agree to provide services to so-called “indigent patients,“ some of whom may not have a payor source for their care. More »

Court in Texas Rules on Hospice Caps

On February 22, 2010, a federal court in Texas ruled that regulations of the U.S. Department of Health and Human Services (DHHS) imposing a statutory cap on Medicare payments for hospice care are arbitrary and capricious and cannot be implemented. More »

Are Potential Kickback Issues Resolved by Payment of Fees to Third Parties Instead of Hospitals to Get on “Vendor Lists” or to Participate in “e-Discharge” Systems?

Payments by post-acute providers to be placed on “vendor lists” or to participate in “edischarge” systems may constitute prohibited kickbacks in violation of the federal antikickback statute. First, payments to be placed on vendor lists in order to get referrals are inappropriate because post-acute providers are not vendors. More »

Patients’ Right to Freedom of Choice of Hospices in Hospitals

All providers are required to abide by patients’ right to freedom of choice. There are a number of sources of this right as follows: 1) All patients have a common law right, based upon court decisions, to control the care provided to them, including who renders it. More »

Skin Changes At Life’s End

In April of 2008, wound care experts met for a round table discussion of the occurrence of Skin Changes At Life’s End (SCALE). The condition of a patient’s skin can provide a great deal of insight into his/her internal health. Illnesses that usually worsen and result in death are frequently accompanied by pressure ulcers. SCALE, therefore, is a term for the compromise of the skin organ during the end stages of life. More »

Use of Preferred Provider Agreements by Discharge Planners/Case Managers

Many hospitals refer patients on a regular basis to post-acute providers; such as home health agencies, private duty home care agencies, hospices, and home medical equipment (HME) companies. Relationships with post-acute providers assist hospitals with controlling their length of stay (LOS), an essential component of financial viability. Consequently, positive relationships with post-acute providers are essential to the success of discharge planners/case managers. More »

Standards of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) Unlikely to Support Practices of Hospitals That Treat Post-Acute Providers as “Vendors”

Post-acute providers continue to be “plagued” by hospitals that claim that post-acute providers cannot enter hospitals and/or gain access to patients to coordinate post-acute services because they are “vendors.” Some hospitals claim that access by "vendors" is prohibited by JCAHO standards. Other hospitals may permit access by post-acute providers only if they comply with complex, inapplicable restrictions that hospitals claim are based on JCAHO standards. More »

Part 1: Continuous Care in Hospice – The misunderstood service with great benefits for patients and providers

Perhaps the most misunderstood and least implemented service of the Medicare Hospice Benefit is Continuous Care. It’s been called everything from “double dipping” by providers who don’t understand how it works and believe competitors who use it are defrauding the government to a “godsend” by families who have been able to honor the wishes of a patient who didn't want any more trips to a hospital. More »

Part 2: Continuous Care in Hospice – The misunderstood service with great benefits for patients and providers

To review, in the Continuous Care scenario illustrated in Part 1, Continuous Care was provided for a total of 9 hours on day 1, 23 hours on day 2 and 12 hours on day 3, when the patient came off Continuous Care and resumed Routine Home Care. Because all three days met both the 8 minimum and 50% skilled rules, Medicare could be billed for 44 hours of Continuous Care at $34/hour or $1496. More »

Part 1: Marketing Hospice Services - Use of Preferred Provider Agreements with Physicians

Many hospices receive more referrals from physicians than from any other source. In addition, physicians routinely supervise the care that hospices render to patients they refer. Consequently, positive relationships with physicians who are willing to make referrals to hospices are essential to the success of hospice providers. More »

Part 2: Marketing Hospice Services - What Can Hospices Give to Discharge Planners/Case Managers?

Discharge planners, case managers, and social workers certainly cannot accept cash payments from providers in exchange for referrals of patients. The Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services, the primary enforcer of fraud and abuse prohibitions, has also clearly stated that providers may not give gift cards/certificates to referral sources. More »

Part 3: Marketing Hospice Services - Frequently Asked Questions about the Use of Consulting Physicians/Medical Directors

Discharge planners, case managers, and social workers certainly cannot accept cash payments from providers in exchange for referrals of patients. The Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services, the primary enforcer of fraud and abuse prohibitions, has also clearly stated that providers may not give gift cards/certificates to referral sources. More »

Part 4: Marketing Hospice Services – Hospices Are Not Vendors

Some hospitals and skilled nursing facilities (SNF’s) refer to hospices as “vendors” and require them to follow the policies and procedures related to “vendors.” These may include, for example, a requirement for representatives of hospices to sign in when they arrive at hospitals and SNF’s to coordinate services in Purchasing Departments.
On the contrary, post-acute providers, such as hospices, are not “vendors” and should not be treated like “vendors.” More »

Part 5: Marketing Hospice Services – Patients’ Right to Freedom of Choice of Providers in Hospitals

All providers are required to abide by patients’ right to freedom of choice. There are a number of sources of this right as follows: 1) All patients have a common law right, based upon court decisions, to control the care provided to them, including who renders it. Thus, when patients voluntarily express preferences for providers, their choices must be honored, regardless of payor source, level of care, or type of treatment. More »

Part 6: Marketing Hospice Services - What Can Discharge Planners/Case Managers Accept from Providers Who Want Referrals?

Discharge planners, case managers and social workers certainly cannot accept cash payments from providers in exchange for referrals of patients. But what can they accept from providers who want referrals? What about non-cash items that have a relatively low value? What about acceptance of referrals to provide services in the evenings and on weekends on behalf of providers who receive referrals from discharge planners/case managers? More »

Use of Preferred Provider Agreements by Discharge Planners/Case Managers

Many hospitals refer patients on a regular basis to post-acute providers; such as home health agencies, private duty home care agencies, hospices, and home medical equipment (HME) companies. Relationships with post-acute providers assist hospitals with controlling their length of stay (LOS), an essential component of financial viability. Consequently, positive relationships with post-acute providers are essential to the success of discharge planners/case managers. More »

About Home Telehealth: Inroads Made to Date in Service Delivery

Home telehealthcare is one of the most rapidly developing service frontiers in healthcare delivery today. Among its most sought after features: a range of telemonitoring devices and services helping to keep patients relatively well and reducing use of costly emergent and acute care services. By regularly tracking co-morbid patients at home, telehealth systems can signal nurses for scheduling timely, targeted interventions to patients, as needed. More »

Where Have All The Miles Gone?

There are many ways to come at the challenge of improving the bottom line. While growing the business certainly brings the most kudos from corporate management, boards and investors, trimming costs without sacrificing quality can often be quicker and more predictable. More »

Deliver Best What Your Customers Want Most

If you are like most agency owners/administrators in Home Health, Private Duty and Hospice, you are surrounded by competitors. You are constantly thinking about how to gain market share. You want to differentiate your agency from your competitors so that current AND new customers will be turning to you more frequently. More »

Standing Orders and Guidelines: Benefits and Advantages in Hospice

Because the symptoms of hospice patients, progressing towards the end of life, are identical for many different diagnoses, many hospices have adopted Standing Orders or Guidelines for use by the Interdisciplinary Team in dealing with these symptoms. Standing Orders are generally a standardized set of directives that either the Physician may either approve upon the patient's admission in its entirety or modify them to fit the individual needs of the patient or the physician's preferred method of treatment. More »

Hospice: A Growing Concept In America

Hospice is not a place. Rather hospice is a philosophy of caring, providing palliative or comfort services to an individual who has reached the decision that the treatment options remaining for their condition may compromise their quality of life and their ability to live their last days as they wish. More »