HPC Healthcare, Inc. Administrative/Operational Policy and Procedure Manual

Transcription

1 Operational and Procedure Manual 1 of 7 Subject: Corporate Compliance Plan Originating Department Quality & Compliance Effective Date 1/99 Administrative Approval Review/Revision Date(s) 6/00, 11/99, 2/02, 2/04, 2/06, 4/08, 11/08, 4/09 This policy applies to HPC Healthcare, Inc. and all its subsidiaries, unless otherwise noted below. POLICY It is the policy of HPC Healthcare, Inc. and its current and future affiliates (collectively, HPC ), which currently includes LifePath Hospice, Inc., Good Shepherd Hospice, Inc., HPC Pharmacy Services, LLC, Axis Palliative Healthcare, LLC, and HPC Staffing Services, LLC to promote an organizational culture for Hospice and Palliative care that demonstrates: A. Ethical business practices; B. Adherence to applicable rules, regulations, laws and standards; C. Appropriate decision making based on a commitment to Hospice Core Values; D. Improved quality, efficiency and consistency of patient care; E. Flexible, innovative systems that allow prompt adaptation to changes in the healthcare environment. DEFINITIONS A. Abuse - incidents or practices which are inconsistent with accepted sound medical, business or fiscal practices, directly or indirectly resulting in unnecessary cost to the government or third party payor; improper reimbursement; or reimbursement for services which fail to meet professionally recognized standards of care or which are medically unnecessary. B. Fraud - an intentional deception or a misrepresentation of material fact that could result in unauthorized benefit to oneself or some other person. C. Staff unless otherwise specified herein, staff includes both employees and volunteers of HPC. D. Medical Staff unless otherwise specified herein, Medical Staff includes both employed/contracted licensed physicians and employed/contracted advanced registered nurse practitioners. RESPONSIBILITIES A. The HPC Healthcare Board of Directors, the Hospice Board of Directors and Senior Staff strongly endorse and support the Corporate Compliance Plan; they allocate the appropriate resources to ensure an effective program. B. All HPC management and staff must agree to abide by the principles of the Corporate Compliance Plan and Code of Conduct (attachment 1). C. The Executive Vice Presidents, Vice Presidents, and Executive Directors are responsible for the development and implementation of certain components of the organization s Corporate Compliance Plan. These leaders will: 1. Develop department specific compliance policies and procedures and obtain approval from the Corporate Quality and Compliance Committee (CQCC). 2. Ensure education regarding adopted policies and procedures is provided in consultation with Quality and Compliance Department to all affected staff members. 3. Assist the Compliance Department with the development of performance measures for auditing compliance in potential risk areas. 4. Analyze audit findings to identify trends and opportunities for improvement. 5. Determine the need for staff education or revision of policies, procedures, or processes. 6. Communicate new developments or providing consultation relating to compliance in their areas of expertise.

2 Operational and Procedure Manual 2 of 7 PLAN COMPONENTS A. Policies and Procedures B. Chief Quality and Compliance Officer C. Corporate Quality and Compliance Committee D. Training and Education E. Communication F. Audit G. Disciplinary Guidelines H. Corrective Actions POLICIES AND PROCEDURES Code of Conduct A. The Code of Conduct is not intended to be all-inclusive, but provides a reference for appropriate ethical conduct. Each new staff member is oriented to the Code of Conduct; staff review and acknowledge acceptance of these standards in writing. B. Hospice is committed to compliance with all federal, state and private insurer standards, inclusive of those related to prevention of fraud and abuse. All staff has an obligation to report any known or suspected misconduct. C. The Code supports the mission of HPC which is to provide quality hospice and palliative care and relieve the suffering of those in our communities affected by life-limiting and other serious illnesses and end of life issues, maintaining the highest ethical standards, so all may live as fully and comfortably as possible. D. As stated in the Core Values statements, HPC expects all staff, volunteers, providers of contracted services, and members of the Board of Directors to adhere to applicable ethical, legal and regulatory standards. E. Board Members and staff will not contribute to or participate in any activities which may be construed as fraud, abuse, a conflict of interest, or misconduct. Potential Risk Areas A. Administrative: 1. HPC s hospice affiliates must meet all Medicare conditions of participation and state and federal licensing regulations and laws pertaining to hospice programs. 2. HPC s pharmacy affiliate must meet all state and federal licensing regulations and laws pertaining to the operation of pharmacies. 3. HPC s palliative care affiliate must meet all state and federal regulations and laws pertaining to the operation of physician and nurse model palliative care programs. 4. HPC s staffing services affiliate must meet all the state and federal regulations and laws pertaining the operation of a licensed staging agency. 5. HPC s hospice affiliates must retain the professional management for all patient care regardless of level and site of care. 6. Patient medical records must contain accurate information and dates. 7. Marketing materials must accurately portray the nature of the care and services provided. 8. No agent of the organization may offer or accept incentives to actual or potential referral sources. Ethical marketing activities must be practiced. Improper solicitation activities are prohibited. 9. Late referral of patients should be analyzed and addressed. 10. Contractual agreements may not be created with individuals or organizations that have been excluded from participation in federal and state programs. 11. The Chief Quality and Compliance Officer (CQCO) and Legal Department will review any OIG Special Fraud Alerts to evaluate applicability to HPC and for compliance. Any conduct that is sanctioned in the alert must cease; steps must be taken to prevent reoccurrence. 12. HPC should educate contracted providers about appropriate billing for services covered by the hospice benefit. B. Patient Admission: 1. Patients are admitted to HPC s hospice and palliative care affiliates without regard to age, gender, nationality, race, creed, sexual orientation, disability, or ability to pay.

3 Operational and Procedure Manual 3 of 7 2. Patients admitted to HPC s hospice affiliates must have a terminal illness and a life expectancy of six months or less to utilize federal or state hospice benefits, although they may enroll in the Hospice program with a life expectancy of twelve months or less. 3. Appropriateness for admission to the hospice programs of HPC s hospice affiliates is based upon prognostic indicators and medical judgment. The Medical Director or designee documents factors that have influenced his/her judgment. 4. HPC s hospice affiliates must inform the patient/family prior to admission that by electing the Hospice Medicare benefit, they waive rights to curative treatment. Only the patient or legal representative may consent to care. 5. Verbal orders for care, treatment, or certification must be recorded and authenticated by the physician. 6. An accurate diagnostic code to reflect the terminal diagnosis of patients admitted to HPC s hospice affiliates should be identified. C. Provision of Care: 1. Care provided patients of HPC s hospice affiliates must be delivered according to the Plan of Care developed by the hospice interdisciplinary group (IDG). The plan must be based on an accurate assessment of patient/family needs and be inclusive of scope, intensity, and level of services required; Hospice must provide necessary services for the patient/family without regard to cost. 2. HPC s hospice affiliates may not duplicate services of another organization involved in the patient's care. 3. HPC s hospice affiliates must make most core services available to patients by employed staff. 4. Competent care and services must be provided at an acceptable standard of care. 5. Volunteers must be provided by HPC s hospice affiliates when indicated. Volunteers must be screened, oriented and supervised as employed staff. 6. Hospice services provided to patients of HPC s hospice affiliates who are leaving the program must be concluded according to policy and procedure and documented. 7. The process of preparing a patient for discharge from the Hospice programs operated by HPC s hospice affiliates must be concluded according to policy and procedure. Decisions may not be based on cost. D. Physician Services 1. A physician must re-certify in writing that the patient is continues to be eligible for hospice services provided by HPC s hospice affiliates at designated intervals. 2. Hospice services are not billed for medicare and medicaid patients who are not re-certified. 3. The Medical Director provides oversight specific for patients who have been in the hospice program of an HPC hospice affiliate over six months. 4. The Medical Director is responsible for the education of team physicians regarding the hospice certification/re-certification process. 5. A physician may not make referrals to HPC for designated services if he/she or his/her immediate family gains financially, unless the relationship fits within legally recognized exceptions. E. Nursing Homes (NHs): 1. A written contract with a facility must be executed before care is rendered. 2. HPC s hospice affiliates retain the responsibility for professional management of hospice patients who reside in nursing homes. 3. Services to NH patients may not be duplicated. The scope of services should include those unique to HPC. 4. Reimbursement to a nursing home for room and board provided to a Medicaid hospice patient shall not exceed what the nursing home otherwise would have received if the patient had not been a hospice patient. 5. Patients who elect to receive services from the NH related to their terminal illness under the skilled Medicare benefit will not be eligible to enroll or remain in the hospice program provided by HPC s hospice affiliates. F. Assisted Living Facilities (ALFs): 1. The service agreement between the facility and patient should be reviewed at the time of admission to determine the extent and type of services the facility has contracted to provide. The hospice Plan of Care should be reflective of this agreement and avoid duplication of services. 2. State requirements related to admission criteria and licensure levels for the ALF must be observed. G. Claim Development and Submission: 1. Bills should reflect the appropriate level of care and point of service. 2. Third parties should be billed for services that are justified and documented. Appropriateness for continued HPC care should be documented and not falsely amended. 3. Billing practices must conform to regulations, policies and procedures. 4. Billers may not receive financial incentive based on the number of claims submitted.

4 Operational and Procedure Manual 4 of 7 5. Any overpayments from a third party payor are refunded in a timely manner. 6. A physician authenticated hospice Plan of Care (initial certification of terminal illness) must be on file before billing. 7. Patients may not be transferred from one hospice to another to avoid reimbursement caps. 8. The Executive Vice President/Operations and Finance is responsible for the preparation and submission of annual cost reports according to the guidelines established by Center for Medicare/Medicaid Service (CMS). a. Any audit adjustments from the prior year are identified as protested amounts. b. Any errors are reported per fiscal intermediary guidelines. Anti-kickback & Self-referral A. All contracts with potential or actual referral sources are reviewed for compliance with applicable statutes, regulations and standards prior to execution. B. Federal health care programs may not be billed for care and services for patients who are referred to the agency through arrangements that are in violation of the Stark Physician Self-referral law or anti-kickback statutes. C. HPC does not provide payments, gifts or services to potential referral sources for the purpose of inducing referrals. Record Retention A. All medical records and billing, with claims documentation and data to support the cost report, must be retained for the time period required by federal and state regulations. B. All records that protect the integrity of the HPC compliance process, employee training documentation, and monitoring/auditing records will be retained for a minimum of seven (7) years. Compliance and Job Performance A. The performance evaluation for all staff will include a rating related to the promotion of and the adherence to the HPC Compliance Program and Code of Conduct. B. Management will be rated on the provision of adequate instruction to their staff and the reasonable detection of any instances of noncompliance. CHIEF QUALITY AND COMPLIANCE OFFICER (CQCC) A. The Chief Quality and Compliance Officer (CQCO), with the support and assistance of the Legal Department as appropriate, is responsible for the planning, designing, implementing and maintaining a system-wide HPC Compliance Program with applicable policies and procedures. B. The CQCO promotes an awareness and understanding of positive ethical and moral principles consistent with the mission, vision, and values of the organization and those required by law. C. The CQCO reports to the CEO, has the appropriate authority to meet the responsibilities of the position, and has direct access to legal counsel and the Hospice Board of Directors. D. Responsibilities of the CQCO: 1. Implements program to ensure compliance with applicable federal and state laws and regulations. Periodically revises program to reflect changes prompted by organizational need, governmental regulatory changes, and third party requirements. 2. Directs system-wide audits to monitor organizational compliance. Prompt action will be taken to address any problems identified during monitoring. 3. Develops policies and procedures and assists others to integrate standards intended to improve HPC efficiency and quality of services, and to minimize vulnerability to fraud and abuse. 4. Reviews complaints, concerns, questions, and corrective actions relative to compliance issues in all departments or with contracted providers. 5. Encourages the reporting of suspected fraud and other misconduct. 6. Provides and coordinates orientation, education and training relevant to compliance. 7. Maintains a system of reporting to the Board of Directors, President/CEO and General Counsel. 8. Coordinates personnel issues with Human Resources.

5 Operational and Procedure Manual 5 of 7 9. Maintains a log to record the questions posed to and responses received from any regulatory or accrediting organization. Any department that communicates with third party payors will keep the same type of records. CORPORATE QUALITY AND COMPLIANCE COMMITTEE (CQCC) A. The CQCC advises the CQCO and assists with the implementation of the Quality and Compliance Program. B. Committee Responsibilities: 1. Assess the organization's regulatory environment, legal requirements and specific risk areas. 2. Review, and develop policies and procedures. 3. Recommend internal systems and controls to execute standards, policies and procedures. 4. Determine strategies to promote organization program compliance. 5. Develop systems to seek, evaluate and respond to problems or communications. 6. Analyze the findings of internal and external audits; recommend actions for repetitive issues. C. Committee Chairperson/Meetings: 1. The CQCO will serve as Co-Chairperson with the Board of Director/designee for the Corporate Quality and Compliance Committee. 2. The committee will meet on a quarterly basis; special meetings may be called at the discretion of the CQCO or CEO. 3. Minutes will be kept for each meeting. 4. The CQCO will be responsible for reports to the CEO and Board of Directors. D. Quality and Compliance Report will be made at least annually to the CEO and Board of Directors. TRAINING AND EDUCATION A. All HPC staff members are required to attend initial orientation to the Quality Compliance Program and successfully complete annual training. 1. Strict adherence to the Corporate Compliance Plan and Code of Conduct is required and is a condition of employment. 2. Performance evaluations will assess the individual s adherence to ethical conduct. B. Designated staff must attend periodic mandatory training activities as requested by the CQCO or Senior Staff. C. Initial orientation will include the Corporate Compliance Program, fraud and abuse laws, false claims laws, whistleblower protections, federal health care program requirements, claims development and submission, patient rights, corporate ethics, and marketing practices. D. Specific training will be presented to those who perform in areas identified as high risk. Ongoing staff education is provided when existing policies or regulations are changed. E. Senior staff, Executive Director, directors and managers must receive training that includes: 1. Government and third party payor reimbursement principles. 2. Providing hospice services with the proper authorization. 3. Compliance with Medicare Conditions of Participation. 4. Duty of reporting misconduct. 5. Improper clinical record alterations. 6. Remuneration regarding referral inducement. 7. Proper documentation and coding of services. F. Meeting Educational Requirements: 1. Education requirements are mandatory. 2. Receipt of required education and training will be a factor in the annual performance evaluation. 3. The Education Department will maintain education and training records for at least five (5) years. COMMUNICATION A. Access to the CQCO: 1. Any staff or contracted service member shall report suspected misconduct, impropriety, fraud or abuse. Reports are confidential and may be anonymous or directly communicated to the CQCO. Reports may be made by: a. Alert Line b. c. Voice Mail d. Written documentation

6 Operational and Procedure Manual 6 of 7 e. Direct verbal communication 3. Management may not divert reports of potential misconduct or fraud and abuse violations from staff nor institute any form of retaliation. 4. Staff reports related to compliance issues are confidential; under certain circumstances, a staff member may be required to discuss a case under question with governmental authorities. B. Procedure 1. Any staff member may seek clarification or ask questions about HPC policy, practice or procedure from the CQCO. Potential misconduct or suspected violations must be reported. 2. The CQCO will log questions, as they arise, with the nature of the investigation and results. 3. Policies, procedures, standards or protocols will be updated and communicated as indicated. AUDITS/MONITORING A. Monitoring with the use of recognized performance measures will be used to conduct audits. At minimum the audits will include: 1. Compliance with Federal/State and HPC regulations, Conditions of Participation, regulations, laws, or policies related to claims development and submission, diagnostic coding, and reimbursement. 2. Cost reporting, marketing, and admission appropriateness. 3. Specific areas identified by OIG risk areas for hospices, Fraud Alerts, governmental initiatives and others. 4. Any area of organizational concern or any problem area identified by prior audit. B. Monitoring techniques to be utilized, but not limited to, are: 1. Staff interview or questionnaire 2. Medical Record review 3. Other record reviews C. Detected overpayment for service will be returned immediately to the payor with appropriate documentation and explanation for the refund. DISCIPLINARY GUIDELINES A. Disciplinary : 1. All staff is accountable for compliance to applicable regulations, laws, standards, and elements in the HPC Compliance Plan. Management staff is also accountable for their subordinate s compliance. 2. Disciplinary action will occur for violations; it may include verbal or written counseling, suspension or termination depending on severity and consequences of the misconduct. 3. Disciplinary action will be prompt, managed on a case-by-case basis, and made on an equitable and fair basis. 4. Management has an obligation to discipline staff in a consistent and appropriate manner. B. Initial Employment: 1. Applicants are required to disclose any health care criminal convictions that may have occurred within the ten (10) years prior to application for employment at HPC. HPC may employ no person who has been convicted of a criminal healthcare offense within this ten (10) year period. 2. All potential employees will have reference and background checks. 3. A criminal background check will be conducted on all staff. 4. Each new staff member s name will be checked with the OIG List of Exclusions C. Ongoing Employment: 1. Any staff member who is charged with health care criminal charges must be removed from any direct involvement in the federal health care program. If this is not possible, the person will be suspended. 2. Staff members who are convicted of criminal charges are subject to termination. 3. Management will be sanctioned for failure to provide adequate training or for failure to detect noncompliance among staff members. D. Contractual Relationships 1. HPC will not enter into a contractual arrangement with any agency or individual who has been convicted of a health care related criminal offense or is ineligible for participation in federal and state programs. 2. The person negotiating the contract is responsible for verification of eligibility for participation. 3. HPC will sever relationships with any contracted service agencies or individuals that are on the excluded from participation in federal and state programs during the life of the contract.

7 Operational and Procedure Manual 7 of 7 CORRECTIVE ACTIONS A. The CQCO, assisted by management officials if requested, will conduct a prompt investigation of any reported, detected, or suspected misconduct to determine if a violation exists and initiate corrective action. B. The CQCO will seek advice from the HPC General Counsel and plan an appropriate course of action, for possible compliance violations. The CQCO in conjunction with the General Counsel and the President/CEO will make any referral to criminal and/or civil law enforcement. C. Compliance violations may or may not have monetary implications. 1. Normal repayment channels should be utilized for over-payment if no fraud or false claim liability exists. 2. The Manager of the Accounts Receivable is responsible for the prompt reporting of overpayments, billing errors, and violations or deviations from the Corporate Compliance Plan to the CQCO. D. The CQCO will take prompt actions to secure any documents or evidence relevant to an investigation. Staff members may be removed from their current job function, when the integrity of an investigation is threatened E. Reporting: 1. Any demonstrated violation of criminal, civil, or administrative law will be reported to the appropriate governmental agency within sixty (60) days. 2. The report will provide all evidence of the alleged violation and the potential cost impact. This will be prepared according the CMS guidelines. 3. Appropriate corrective action, including return of overpayment, will be promptly taken. PLAN EVALUATION The Corporate Compliance Program will be evaluated for on-going effectiveness.