“What to do if the OIG comes calling”…

1. “What to do if the OIG comes calling”… (Or how one agency dealt with the OIG’s unexpected visit!)

2. Introductions& a Pre-Test! • Barbara Hansen, MA, RN, CWON, Manager, Samaritan Evergreen Hospice • Colleen S. Fair, BA, CHC, Compliance Officer, Samaritan Health Services

3. What is the OIG (& Why Should Hospice Care?) • What is the OIG? • “Office of the Inspector General” • Established in 1976 • Over 1700 employees • Mission: to protect the integrity of Dept. of Health and Human Services (HHS) programs as well as the health and welfare of program beneficiaries. • Efforts to fight waste, fraud and abuse in Medicare, Medicaid and more than 300 other HHS programs.

4. OIG’s “Six Components” • Immediate Office of Inspector General (IO) • Office of Audit Services (OAS) • Office of Evaluation and Inspections (OEI) • Office of Management and Policy (OMP) • Office of Investigations (OI) • Office of Counsel to the Inspector General (OCIG)

5. Immediate Office of Inspector General (IO) • Responsible for the overall fulfillment of the OIG’s mission and • for promoting effective management and quality of the agency’s processes and products

6. Office of Audit Services (OAS) • Conducts independent audits of HHS programs and/or HHS grantees and contractors. • Examine performance of HHS programs and/or grantees in carrying out their responsibilities and • Provide independent assessments of HHS programs and operations.

7. Office of Evaluation and Inspections (OEI) • Conducts national evaluations of HHS programs from a broad issue-based perspective. • Focus on preventing fraud, waste and/or abuse and • Encourage efficiency and effectiveness of HHS programs.

8. Office of Management and Policy • Provides mission and administrative support to the OIG. • Ensures the agency has the resources it needs.

9. Office of Investigations (OI) • Conducts criminal, civil and administrative investigations of fraud and misconduct related to HHS programs, operations and beneficiaries. • Uses state-of-the art tools and technology to assist OIG Investigators • Goal is to become the world’s “premier health care law enforcement agency”.

10. Office of Counsel to the Inspector General (OCIG) • Provides timely, accurate and persuasive legal advocacy and counsel to the Inspector General and OIG’s other components. • The OCIG acts as a full-service, in-house legal counsel.

11. The OIG’s Annual Work Plan • Sets forth various projects to be addressed during the fiscal year by the components of the OIG. • Almost every year for the past 15 years, there has been an aspect of the Annual Work Plan which focuses on Hospice! • Who recalls “Operation Restore Trust”?

12. Summary of OIG Work Plans Dealing with Hospice 1997-2012 • Hospice Marketing Practices and Financial Relationships with Nursing Facilities (New) • Medicare Hospice General Inpatient Care • Hospice Utilization in Nursing Facilities • Physician Billing for Medicare Hospice Beneficiaries • Trends in Medicare Hospice Utilization • Medicare Hospice Care for Nursing Home Residents: Services and Appropriate Payments • Hospice Payments to Nursing Facilities • Hospice: Plans of Care and Appropriate Payments • Oversight of Hospice providers • Hospice Payments and Plans of Care

13. OIG & Hospice Issue Work Plans 1997-2012 (Cont.) • Plans of Care • Hospice Payments to Nursing Homes • Plans of Care • Use of Continuous Care By Hospice Agencies • Eligibility for Hospice Care • National Hospice Deficiencies • Hospice and Hospital/Skilled Nursing Facility Overpayments • Part B Payments For Hospice Patients • Hospice Services Provided to Patients in Nursing Facilities • Hospice: Referral Sources and Patient Care

14. 2012 Work Plan Focus • Hospice Marketing Practices and Financial Relationships with Nursing Facilities (New) • We will review hospices’ marketing materials and practices and their financial relationships with nursing facilities. In a recent report, OIG found that 82 percent of hospice claims for beneficiaries in nursing facilities did not meet Medicare coverage requirements. MedPAC, an independent congressional agency that advises Congress on issues affecting Medicare, has noted that hospices and nursing facilities may be involved in inappropriate enrollment and compensation. MedPAChas also highlighted instances in which hospices aggressively marketed their services to nursing facility residents. We will focus our review on hospices that have a high percentage of their beneficiaries in nursing facilities. (OEI; 02-10-00071; 02-10-00072; expected issue date: FY 2012; work in progress)

15. 2012 OIG Hospice Work Plan, Cont. • Medicare Hospice General Inpatient Care • We will review the use of hospice general inpatient care from 2005 to 2010. We will assess the appropriateness of hospices’ general inpatient care claims and hospice beneficiaries’ drug claims billed under Part D. Federal regulations address Medicare CoPs for hospice at 42 CFR Part 418. We will review hospice medical records to address concerns that this level of hospice care is being misused and to determine the extent to which drugs are being inappropriately billed to Part D. (OEI; 02-10-00490; expected issue date: FY 2012; work in progress)

16. “It was just a normal Tuesday afternoon…” • A woman walked in our front door; she was not wearing an ID badge. • She did not introduce or announce herself. • She asked for “the Manager” and • handed me a letter! She did not explain what the letter was about. • I had to make sure I had her contact information if I had questions.

17. The Letter • It was on “Dept. of Health and Human Services” Stationary • Signed by a “Special Agent in Charge”! • It was six pages, with its “attachment” • And page two was actually a “Subpoena DucesTecum” with the bold print at the top of the page: UNITED STATES OF AMERICA • And the next phrase said: “YOU ARE HEREBY COMMANDED TO APPEAR BEFORE” Special Agent…

18. The Letter, Cont. • Asked for copies of 169 patient charts! • (4 pages of names, single spaced!) • LOS ranged from days to > a year and a variety of Hospice diagnoses; • Gave dates going back 4 years for patient records, to 2006; • But the attached list included eighteen patients on service in 2005. • Asked for copies of all claims submitted for these 169 patients.

19. The Letter, Cont. • Documents with all managers’ information, full names, DOB, SS #s, address and telephone numbers. • Documents identifying all current and former employees and contractors, including all above information AND their licenses and continuing education records and performance evaluations.

20. The Letter, Cont. • Information and documents about all individuals (licensed or unlicensed) who managed, coordinated or provided services to Medicare beneficiaries: • Labor logs, sign in/out sheets, time sheets and payroll information that identifies hours worked per individual • And they wanted it all in approximately 4 weeks!

21. What the OIG Asked Said & Asked for • What the subpoena said: it was in connection with the investigation into the submission of possible false, fraudulent or otherwise improper claims to the Federal healthcare programs!

22. The Letter, Cont. • What they asked for: did they realize the sheer volume of documents requested? • The first 8 patient records copied = >500 pieces of paper—and that was just the paper portion of their medical records! • Printing out the electronic notes was going to be another 400-800 pieces of paper! • Copying all of the weekly staff log sheets x 4 years would be >5000 pieces of paper! • Copying all of the staff performance evaluations + continuing education records = ~1000 sheets of paper!

23. Our Initial Responses • “Why Us?” • “Did someone call the OIG to complain about us?” • “Who could have possibly done this?” • A patient? Family member? Former staff person? • “What could we possibly have done to deserve this?!” • “Did we possibly do something that triggered this audit?” • “We’ve been accused—will some folks then assume we might be guilty?!”

24. Strategies We Employed • Involve as many “Helpers” as you possibly can! • Risk Management • Compliance • Patient Financial Services • Health Information Management • Legal department • Professional Development and Human Resources • Hire an Attorney who is familiar with working with the OIG or other government auditors!

25. Strategies, cont. • Cooperate and negotiate! • It’s okay to ask for clarification on what they want. • Point out the volume of information or any “redundancies” they are requesting. • Try to glean what issue they are actually focusing on/looking for. (This will guide your own internal chart audits.) • It’s okay to clarify and negotiate their initial timelines.

26. Internal Strategies • Where are all of the patient records? • How much is on paper and how much electronic? • Where is all of the employee/contractor data? HR? Professional Development? Storage? • How quickly can we access the requested materials? • Do we have a secure, private location to set up as a “War Room”? • Do we need to print out paper copies of all of the EMR documentation? Or is it in an electronic format that is “transferrable”?

27. Internal Strategies Cont. • Does the OIG cover letter match what is requested in their attachments? • What format do they want the materials? • How do you attain “single page tagged image file format at 300 dpi” that is “OCR” (optical character recognized)? • How does one convert paper copies to an electronic format? What is a “flat file”? How do you label each page? • You may have to create “easily-copy-able” copies first! • Where can you get your paper copies converted? Is it worth it to hire an outside company to do this? • How will you transport your documents in a secure manner?

28. Internal Strategies, cont.:Issues with Document Conversion • Is it worth it to rent an additional copier(s)? • Do you have the extra staff on hand for the (tedious) chore of copying? • Do you have enough staff (and printers) to print out all of the EMR documents? • Do you have staff who are experienced in doing chart reviews/audits? • Do they know what they are looking for? • Can you afford to pay for overtime?

29. Internal Strategies, Cont. • Have staff meetings to discuss the situation. • Need to educate AND support staff. • Provide frequent updates to staff. • Educate staff about the process—ensure they understand what you doing and what their “job” is. (For many, it will be to take care of patients!) • Make a spreadsheet or table: • List specific tasks • Specify who will do what • Specify their individual “deadlines”

30. Preparing Your Defense: Do Your Own Chart Audits • Do chart audits. • Have a 2nd person review the chart to confirm any findings that do not meet your standards. • Find cross-references for supportive documentation, if you can! (e.g. Fax date/time stamps, meeting attendance logs, etc.) • Identify needed documents. • Meticulously note your findings! • Create spreadsheets • Review with all internal chart auditors

31. Strategies to Support Your Case • Create your own spreadsheet. • Never assume the OIG staff fully understand the Medicare rules and how you feel you met them! • Refute their findings everywhere you can! • Provide the evidence to support your claim. • Be meticulous and painstaking!

32. Mistakes We Made: 2005-2010 • Regarding the all-important MD Signatures: • We allowed our Medical Director to sign but not date documents. • We then had clerical staff date stamp his signed documents. • Guess what? Sometimes they were interrupted! • We used many different staff to do different pieces of this process. • Sometimes there was less than ideal follow up or attention to details.

33. Mistakes We Made 2005-2010, cont. • Regarding filing of important documents: • We allowed many folks to do this to “help out”: • Clerical staff • Field staff who had time • Trained office volunteers • Hospital staff on light duty • We allowed all of those same folks to do closed chart audits. • And at least one of our full-time clerical staff had dyslexia!

34. Mistakes We Made 2005-2010, cont. • Other problems with the filing and chart audit processes: • It’s possible there were “varying levels of understanding” about the processes (even where certain forms should be filed.) • We “recycled” the chart tabs from closed charts. This made it even more difficult to find forms. • Certs. and Recerts. were filed toward the back of the paper record. Why? • No one person truly “owned” these processes.

35. Take-Away Lessons • Important forms in a patient’s record should be readily accessible. (So if they are “missing”, you can follow up right away.) • E.g. If a paper form was misfiled, where to look? All patients on service at that time? Or alphabetically “near”? • Staff need to understand the importance of their piece of the process. (It’s our job to educate them.) • Standardize all of your processes and support them with policies, work instructions, flow sheets, etc.

36. Take-Away Lessons, Cont. • Go electronic with your processes as much as you can! This really helps with ongoing monitoring of missing pieces. • The > the number of folks doing a process, the > the chance of variability in the result. • Limit the number of people doing important tasks, if you can!

37. When Does It End?(Is the phrase “No news is good news” really ever true?) • Will you get a letter saying “Never mind!”? • Don’t expect to hear anything. • You may have to initiate follow up contact. • How will you and your staff find closure?

38. The Pre-Test Reviewed! • And any follow up questions.

39. We hope this never happens to you! Thank you very much!