Breaking Compliance News Blog

Phase 3 Nursing Home Compliance Update!

Posted by Margaret Scavotto, JD, CHC on 12/4/19 10:58 AM

On November 22, 2019, CMS issued a memorandum with an update on the Phase 3 Requirements of Participation. In this memo, CMS advised:

  • CMS will not release updated Interpretive Guidance and training addressing Phase 3 until the second quarter of 2020.
  • But... nursing homes are still expected to require with Phase 3 by November 28, 2019.

Here is what CMS said:

"While the Phase 3 requirements will be effective November 28, 2019 and facilities are required to comply with these and all requirements, our ability to survey for compliance with these requirements will be limited until the Interpretive Guidance is released."

What does this mean??

It means that, right now, nursing homes are required by law to comply with the Phase 3, including the Compliance and Ethics Program requirements - and CMS expects nursing homes to be in compliance.

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Topics: skilled nursing, guidance, compliance, Phase 3

DOJ cracking down on nursing homes

Posted by Margaret Scavotto, JD, CHC on 11/5/19 8:15 AM

The Department of Justice (DOJ) aims to use its Elder Justice Initiative to  pursue more criminal charges in nursing home investigations. Typically, the DOJ uses civil lawsuits to pursue False Claims Act violations against nursing homes. Toni Bacon, a DOJ associate deputy general, explains the shift: "We need to go after cases civilly because they [are] providing grossly substandard care and, in the appropriate case, refer it for a parallel criminal prosecution."

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Topics: Penalties and Enforcement, compliance

CMS' New Affiliate Screening Requirements Are Coming

Posted by Margaret Scavotto, JD, CHC on 10/23/19 7:58 AM

On November 4, CMS' Program Integrity Enhancements to the Provider Enrollment Process final rule goes into effect. 

The "Affiliates" provision of this rule requires Medicare, Medicaid and CHIP providers to disclose to CMS any affiliations with organizations that have had a "disclosable event." Providers who fail to make these disclosures can be denied enrollment - or have their enrollment revoked. The purpose of this new process is to stop fraud and help CMS find parties that have committed fraud.

What's an "affiliation"?

There are five ways a provider can have an "affiliation' with an organization:

  • a 5% or more direct or indirect ownership interest in another organization
  • a general or limited partnership interest (of any percentage) in another organization
  • an interest in which an individual or entity exercises "operational or managerial control over, or directly or indirectly conducts, the day-to-day operations of another organization," by contract of another arrangement. This includes sole proprietorships.
  • when an individual is acting as officer or director of a corporation
  • a reassignment or payment assignment relationship

 

What's a "disclosable event"?

Providers must disclose "affiliations" within the past five years to CMS if the affiliated organization has a "disclosable event:"

  • current uncollected debt owed to Medicare, Medicaid or CHIP
  • current or prior payment suspension
  • current or prior OIG exclusions
  • Medicare, Medicaid or CHIP enrollment denial, revocation or termination

When does this go into effect?

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Topics: Excluded Providers, compliance, vendor screening

Have you tested your compliance hotline lately?

Posted by Margaret Scavotto, JD, CHC on 10/2/19 7:28 AM

The Kansas Medicaid fraud and abuse complaint email inbox went unchecked for 17 months.

According to a report issued by the Kansas Office of the Medicaid Inspector General, 209 emails were unread. 95 of these emails "alleged fraud, waste, abuse, or illegal acts related to Medicaid, MediKan, or SCHIP, or were seeking information on how to report suspected fraud." 42 of these emails contained "partially or wholly substantiated allegations of Medicaid or SCHIP fraud, waste, abuse or illegal acts....

How did it happen?

The complaint inbox went unchecked from August 2, 2017 to January 9, 2019.

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Topics: Hotline, annual review, compliance

CMS Changes SNF Compliance Program Requirements – Again

Posted by Margaret Scavotto & Scott Gima on 9/10/19 7:13 AM

Ladies and gentlemen, long-anticipated compliance program requirements are changing, one more time. Let’s take a look at what has changed – and what hasn’t.

The proposed rule

On July 16, 2019, CMS published a proposed rule that would modify multiple aspects of Phase III of the Long-Term Care Facilities Requirements for Participation (the “Proposed Rule”). The goal of the Proposed Rule is to reduce regulatory burdens and costs, allowing nursing homes to focus resources on providing quality resident care. Some of the most discussed proposed amendments are those to the Compliance and Ethics Program requirements (42 CFR 483.85), which, if finalized, will become effective one year later. With comments from the public due September 16, 2019, our best guess is that enforcement will begin October or November 2020.

Good news: fewer compliance-related F-tags ahead

Nursing homes: LeadingAge (and other associations) successfully lobbied on your behalf. 

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Topics: Affordable Care Act, OIG compliance resources, skilled nursing, compliance

What has compliance done for you lately?

Posted by Margaret Scavotto, JD, CHC on 8/20/19 7:51 AM

At the risk of getting some Billboard top ten 1980’s Janet Jackson lyrics stuck in your head for the rest of the day, I’d like to ask you an important question:

What has compliance done for you lately?

Phrased another way:

How has your compliance program helped your organization this year?

Did your hotline encourage employees to report potential false claims internally, so they could be self-reported? Did this hotline call possibly avoid a whistleblower situation?

Did routine compliance audits find a documentation issue – so you could correct it before it became a widespread problem?

Maybe the compliance department collaborated with the HIPAA Security Officer to run a ransomware and phishing campaign, educating employees about potentially hazardous emails and links. As a result, the Compliance Officer and Security Officer received dozens of calls from employees reporting suspicious emails and links that potentially contained ransomware or malware. Can you put a price tag on potentially avoiding a costly ransomware attack?

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Topics: Compliance Basics, Culture of Compliance, compliance, compliance officer

Why Compliance Should Care About the War on Opioids

Posted by Margaret Scavotto & Scott Gima on 6/18/19 8:51 AM

We have an opioid problem

In the United States, 134 opioid-related deaths occur daily. In 2016, more than 60,000 Americans died from drug overdoses, and two-thirds of those deaths were opioid related. Fentanyl is now responsible for more overdose deaths (28.8%) than heroin. And, three out of four new heroin users first misuse prescription opioids.

In 2017, almost one-third of Medicare Part D beneficiaries received opioids. About 460,000 beneficiaries received high amounts of opioids; 71,000 beneficiaries were at serious risk of misuse or overdose; and almost 300 prescribers had questionable prescribing. Everyone agrees our country has an opioid problem.

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Topics: Quality Assurance, Excluded Providers, Opioids, compliance

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