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Avoid these four nursing home-specific risk areas
While education and cooperation should be priorities of hospices and nursing homes trying to work together, organizations must still be concerned with federal investigators who are on the lookout for fraud and abuse among the two provider types.
Specifically, the Office of Inspector General (OIG) compliance program cites the following hospice/nursing home risk areas:
• overlap in services that a nursing home provides, which results in insufficient care provided by a hospice to a nursing home resident;
• hospice incentives to actual or potential referral sources that may violate the anti-kickback statute or other similar government regulation;
• improper relinquishment of core services
and professional management responsibilities
to nursing homes, volunteers, and privately paid professionals;
• providing hospice services in a nursing home before a written agreement has been
• hospices that overlap services provided by nursing homes. According to the OIG, this often leads to hospices providing insufficient care to nursing home residents.
OIG: Care should be coordinated
"Recent OIG reports found that residents of certain nursing homes receive fewer services from their hospice than patients who receive hospice services in their own homes," the compliance program guidelines stated. The guidelines were published in the Federal Register (64 Fed Reg 39,155-39,168 [July 21, 1999]).
The OIG continues: "Upon review, it was found that many nursing home hospice patients were receiving only basic nursing and aide visits that were provided by nursing home staff as part of room and board when hospice staff were not present."
The answer, OIG says, is for hospices and nursing homes to coordinate care and for hospices to retain professional responsibility for services furnished by nursing home staff. This would include the dispensing of medication and personal care.
The OIG identified many risk areas in its explanation of why hospices should implement a compliance program. These risk areas include the following:
• Incentives to referral sources. Some hospice incentives to actual or potential referral sources, such as physicians, nursing homes, and hospitals, may violate the anti-kickback statute or government regulations.
According to the OIG, investigators have observed instances of potential kickbacks between hospices and nursing homes where unlawful influence can affect patient referral.
OIG is concerned that hospices are paying nursing homes more for "room and board" than the nursing homes would receive if patients were not enrolled in hospice. In Medicaid programs, for example, the normal procedure should be that Medicare pays the hospice at least 95% of the daily nursing home rate, and the hospice
is responsible for paying the nursing home for patient room and board.
"Any additional payment must represent the fair market value of additional services actually provided to the patient that are not included in the Medicaid daily rate," instructs the OIG.
The compliance program guidelines also included concern over arrangements with nursing homes because a nursing home can choose which hospices it wants to partner with, leaving the arrangement vulnerable to fraud and abuse.
Hospice must provide core services
• Improper relinquishment of core services and professional management. OIG reminds hospice providers that core services — nursing, medical, social services, and counseling — must be provided directly to the patient by employees of the hospice. And while other non-core services may be provided under contractual arrangements, the hospice still must retain professional management of those services.
• Providing hospice services in a nursing home before a written agreement is finalized. According to the OIG, a patient residing in a skilled nursing facility or nursing home may elect the Medicare hospice benefit if:
1. The residential care is paid by either the beneficiary/ private insurance or Medicaid if the patient is dual-eligible.
2. The hospice and nursing facility have a written agreement that clearly states the hospice takes full responsibility for the professional management of the patient’s hospice care and the facility agrees to provide room and board.
The OIG compliance guidelines also offer specific examples that might cause investigators to believe there is cause for fraud and abuse concern. These include:
— offering gifts or providing free services to patients or their relatives, physicians, or nursing facilities;
— offering nursing homes below-market-value goods;
— paying above market value for room and board in a nursing facility;
— offering free care to patients in a nursing home;
— providing and paying staff to provide services to nursing homes that otherwise should be performed by nursing home staff.