Emerging Issues in Home Care 2000 and Beyond

1. Emerging Issues in Home Care2000 and Beyond Phil Bradley Long, Aldridge & Norman LLP Atlanta, Georgia Chris Anderson Gentiva Health Services Melville, New York

2. HIPAA Privacy, Security, Communications, & Cultural Behaviors PPS Billing, Billing, Billing Impact to cost reporting False Claims Is it a new ball game? Patient Inducement New restrictions, advisory opinions Corporate Integrity Agreements If you don’t have…. Credit Balance Issues Self- Disclosure Or self suicide? Emerging Issues

3. Who is affected by HIPAA? • All health care organizations that process health data and/or transmit data electronically must comply • Health plans, payors and clearinghouses that process health data must comply • All health care providers electing to conduct covered transactions electronically must comply • Employers, public health authorities, life insurers, medical billing agencies, information system vendors, service organizations and others entities if conducting any of the covered transactions must comply

4. What transactions are covered? • Administrative and financial health care transactions: • Health claims & encounter data • Health claims attachments • Enrollment/ disenrollment in a health plan • Health plan eligibility • Health care payment and remittance advice • Health plan premium payments • Injury reports • Health claim status • Referral certifications and authorizations

5. Compliance Deadlines • 24 months from the effective date of the final rules • Effective date is usually 60 days following publication of the rule • Anticipate all rules to be published by the end of 2000 – Compliance necessary by early 2003 • DHHS Schedule for Publication • Transaction and Code sets – published • Other Standards -- Final Rule Publication dates unclear but expected by end of summer 2000

6. Penalties for Noncompliance • Severe Civil and Criminal Penalties for Noncompliance • Fines up to $25K for multiple violations of the same standard in a calendar year • Fines of up to $250K and/or imprisonment up to 10 years for knowing misuse of individually identifiable health information

7. Costs • Compliance will be very costly and must be budgeted • It has been estimated that compliance with HIPAA will consume 33 cents of every health care dollar between now and 2003 • Hardware & Software Costs • Encryption, Privacy, Monitoring Systems • Operational Costs • Teaching and Training • Changing Behaviors • Monitoring of access and usage

8. HIPAA Compliance Preparation • Raise organizational awareness • Create a leadership plan to oversee the development and execution of appropriate plan • Develop a systematic plan of evaluation and action related to compliance with the regulations • Dedicate resources to the implementation of a strategic plan to address the requirements of the legislation • Discuss the implications of the regulations and create a compliance plan • Develop a plan to educate employees regarding the new regulations • Marketing/PR strategy to address patient/ client/ customer concerns

9. HIPAA Compliance Preparation (Continued) Engage outside consultants or vendors if necessary Review and assess existing systems, policies and procedures Develop and revise policies and procedures Commence modification of existing systems to comply with the regulations Examine contracts with 3rd parties to determine compliance Review impact on relationships with customers, clients, etc. Review insurance policies to determine current/future coverage for breaches of confidentiality Address potential legal liability and risk management issues

10. Prospective Payment System • Fraud and abuse elements • Upcoding • False Claims • Utilization standards • Cost report compliance • Patient Dumping Issues • Learn from the hospital DRG system (400 + CIA’s)

11. More than ever audits will be driven from a clinical standpoint Through out the traditional analysis approach No longer talking about straight technical issues Billing systems will play an integral role in audit approach Prospective auditing (Pre-bill release) Oasis HHRG Grouper Utilization Standards Care Protocols 90 day window of opportunity for full implementation of billing filters at the FI’s. Audit Goals for PPS

12. No existing best practices Learn and not learn from hospital experience. Training is key Billing Training Including: Coding Oasis Medicare Coverage HHRG System Gaming All clinical- billing staff Risks: Patient Complaints Caregiver Complaints Utilization is the driver Communication plan Hotline response system and its tie to compliance System analysis RAP/Claim release process PPS Compliance Preparation

13. Operational difficulties RAP & Cash Flow versus Compliance Physician orders- Verbal start of care orders Significant drops in utilization- impact Risks False Claims Medical Review FI- CERT Program Trending analysis- ORT PPS Compliance Preparation

14. Civil Monetary Penalties Risks Billing System Changes (PPS) Stronger intervention by MFCU’s CERT Program New Requirements have no bearing on the establishment of CIA’s Effect on Qui Tam actions unknown Age old issue- The Rules in Conflict – COP’s, Kickback, False Claims, etc. Keys to Compliance: Billing Audits Prospective Retrospective Relationship with FI Process for handling errors Proper reporting Training Disciplinary Consistency False Claims

15. Advisory Opinion Medical related items not permitted Pagers Beepers Child helmets PPS issue (cherry-picking) Waiver of Co-payments Compliance Preparation Sales Training Contract Training Audit performance Sales Co-payments Other waivers Collaterals Bonus Structures and Performance Criteria Patient Inducements

16. Home Care Model Training General Contracts Cost Reporting Billing Audits Billing Structure after PPS IRO Engagement Compliance Implementation Successful negotiation Mirror existing compliance program Demonstrate adequacy of established safeguards Involvement of senior management Building the culture of proactive compliance versus the “mandated & dreaded” compliance model Corporate Integrity Agreements

17. Compliance Preparation Define credit balances clearly Identify credit balances and eliminate co-mingling Have a policy you can execute Repay true credit balances within 30 days of credible evidence How long is to long to research? Train, Audit, Enforce Credit Balances

18. Is it self suicide? How many forms does this take? What is a self disclosure? Is there practical lessons already learned? Compliance Points Develop key contacts and relationships within the payer community Close relationship and openness with the FI Distinguish errors and inappropriate activity Minimize the need for disclosure at higher levels of the enforcement ladder State FI AG OIG FBI Self Disclosure

19. Closing Comments Phil Bradley 404-527-4000 Pbradley@lanlaw.com Chris Anderson 631-844-7390 Chris.Anderson@Gentiva.com