Office
of Inspector GeneralOffice of Public Affairs
330 Independence Ave., SW
Room 5541, Cohen Bldg.
Washington, DC 20201
(202) 619-1343
Office
of Inspector General
Office of Public Affairs
330 Independence Ave., SW
Room 5541, Cohen Bldg.
Washington, DC 20201
(202) 619-1343
FOR IMMEDIATE RELEASE
Contact: Alwyn Cassil (202) 205-0333
Thursday, Sept. 30, 1999
Inspector General Issues Compliance Program Guidance for Hospices
The Department of Health and Human Services' Office of Inspector
General today issued guidance to help hospice providers design effective voluntary
compliance programs to prevent fraud, waste and abuse in government health programs,
including Medicare and Medicaid.
"Encouraging the health care industry to adopt voluntary compliance programs
is an important prevention strategy to reduce the risk of fraud, waste and abuse
in federal health care programs," Inspector General June Gibbs Brown said.
"The guidance is intended for all hospice providers, whether for-profit
or nonprofit, large or small, urban or rural, with the expectation that each
hospice will tailor a compliance program to meet its particular needs."
The guidance -- "Compliance Program Guidance for Hospices" -- was
first published in draft form in the July 21, 1999, Federal Register
and had a 30-day comment period. The final guidance will be published soon as
a Federal Register notice.
Similar to other guidance already issued by the Office of Inspector General
for clinical laboratories, hospitals, home health agencies, third-party medical
billing companies and durable medical equipment suppliers, the hospice guidance
is based on the following seven elements: 1) implementation of written policies,
procedures and standards of conduct; 2) designation of a compliance officer;
3) development of training and education programs; 4) creation of a hotline
or other measures for receiving complaints and procedures for protecting callers
from retaliation; 5) performance of internal audits to monitor compliance; 6)
enforcement of standards through well-publicized disciplinary directives; and
7) prompt corrective action to detected offenses.
The guidance identifies specific compliance risk areas for hospice providers,
such as admitting patients to hospice care who are not terminally ill; underutilization
of services; improper arrangements with nursing homes; and high-pressure marketing
of hospice care to ineligible beneficiaries.
In fiscal year 1997, Medicare paid about $2 billion to provide hospice care
to about 375,000 beneficiaries. Hospice is a special way of caring for a patient
who is terminally ill. Patients receive a full scope of palliative medical and
support services for their terminal illnesses. Beneficiaries who elect hospice
care forego standard Medicare coverage for conditions related to the terminal
illness, but standard Medicare benefits are provided for conditions unrelated
to the patient's terminal illness.
While many factors can influence when to admit patients to hospice care, it
is important to distinguish between admitting a patient to a hospice program
and certifying a patient for the Medicare hospice benefit. Based on an individual
hospice's admission criteria, some patients may be admitted to hospice care
prior to an estimated six months before death but without reimbursement under
the Medicare hospice benefit. By long-established law, patients can be certified
for the Medicare hospice benefit only when a physician determines that a patient's
life expectancy is six months or less if the illness runs its normal course.
The hospice guidance also includes information on how to assess the effectiveness
of a compliance program. The government views the existence of a compliance
program as a mitigating factor in fraud and abuse cases only if the compliance
program is "effective."
Documentation is key to demonstrating the effectiveness of a provider's compliance
program. For example, the Office of Inspector General strongly recommends maintaining
documentation of the following: audit results; hotline calls and their resolution;
due diligence efforts of business transactions; employee training, including
the number of hours; disciplinary actions; and distribution of policies and
procedures. The documented practice of refunding overpayments and self-disclosing
incidents of non-compliance with federal health care program requirements can
also provide evidence of an effective compliance program.
Note: The hospice compliance program guidance is available on the Internet
at www.hhs.gov/oig. Click on the "What's New" link.
