Eli's Hospice Insider

Take a proactive approach to stop audit trouble before it begins.

The coming year will be as difficult as any the hospice industry has ever faced from a regulation and compliance perspective, the experts lament. Are you ready for the increased scrutiny that healthcare reform, the new conditions of participation (CoPs), and a slew of other regulation-related challenges will bring your way?

Many of the challenges you'll face in the coming year are "oldies," says attorney Connie Raffa with Arent Fox in New York, NY. But that doesn't mean you can rest easy if things appear to be going smoothly at present. Make certain you're on top of these key issues.

Providing hospice care to nursing home patients continues to be a problem under the CoPs. Nursing homes still don't have parallel CoPs holding them to the same regulations which is bound to create ongoing problems, says attorney Marie Berliner with Lambeth & Berliner in Austin, Texas.

As a result, hospice providers have a lot of the burden in making sure the nursing home complies with the regulations, but they don't have a lot of leverage, Berliner adds.

Try this: Documenting coordination of care can show that you are following the CoPs, Berliner says. Any communication between hospice staff and nursing home staff constitutes coordination of care: meetings, conversation between the hospice nurse and the nursing home staff member, and so on.

The hospice agency staff needs to document that they did their part, even if they attempted to coordinate care but couldn't, Berliner explains. Making record of late or unreturned phone calls and other unresponsiveness can help show that you did all you could to meet the requirements even if the nursing home takes action without following hospice procedures and protocols.

Watch out: Be wary of providing services that encourage a nursing home to refer patients to you for hospice care, Raffa warns. Don't be tempted to provide services that the nursing home should be providing.

Also, make certain that the nursing home staff is clear about which drugs are related to the patient's terminal illness. Only the hospice agency should bill for these, and if the nursing home does as well, you are double billing.

MedPAC is looking at patients with a long length of stay, recommending that for patients with a length of stay greater than 180 days, the hospice physician or advanced practice nurse (APN) make a face-toface visit with the patient to determine continued eligibility, Raffa says.

Eligibility requirements state that the patient is expected to live six months or less if the illness runs its normal course. The last part of that statement allows for outliers -- patients who do live beyond six months, Raffa explains. Good documentation can be the key to making certain your care for long length of stay patients holds up under scrutiny.

Crack the books: Study the local coverage determination guidelines your Medicare Administrative Contractor (MAC) has in place, Raffa advises. Make sure you're operating with these criteria in mind. Look especially close at their stand on patients with diagnoses of Alzheimer's disease of failure to thrive. These diagnoses are piquing government curiosity.

Although recent court cases have called into question elements of Medicare's hospice cap, don't expect cap payments to go away. The caps themselves aren't under fire as being potentially unconstitutional.

The question is instead whether the current regulations implement the statute in the way congress intended, Berliner says.

Most likely, if there is any court order as a result of these cases, the regulations will be realigned to match up with the statute, Berliner predicts.

This will benefit those hospices with a lot of long length of stay patients and carry-overs from prior stays.

Don't panic: If you think you might be facing cap liability, there are things you can do, Berliner says. For example, you could try to set money aside now for cap liability in the future. There may be tax implications with setting aside money, however, so consult your attorney before you take action.

Another idea: Use business and marketing practices that will help change your patient mix to stave off future cap problems. You can also look at ways to streamline your business and be more efficient

Do what you should always be doing -- know the regulations and check to see that your staff is following them before there's trouble, says Samira K. Beckwith, president and CEO of Hope Hospice and Community Services in Fort Myers. Fla. Simply training employees isn't enough, Beckwith says. You need to make certain your employees are upto date on all the latest compliance issues, and then put in place checks that check back to make sure they're doing the right thing.

Survey says: If you have any repeat issues that have come up on surveys, make them part of your quality assurance program, Raffa suggests.

This will both improve the problem and demonstrate that you are addressing the issue. Take steps to fix things before the government comes knocking again.