presented by Cathleen Armato
26% of the national budget is spent on Medicare, Medicaid and the Children’s Health Insurance Program (CHIP). The National Health Care Anti-Fraud Association (NHCAA) estimates that our nation loses tens of billions of dollars each year due to health care fraud. This course will review fraud, waste, and abuse and how providers and their employees can participate in compliance efforts to stem the flow of inappropriate payments and preserve these programs for our future. The course will review rules and laws governing home health and hospice, risk areas for home health and hospice, and proactive steps employers and employees can take to remain in compliance with program requirements.
Cat Armato is an experienced executive with 18 years in the home care and hospice industry. She has served in various roles during that time, including VP of operations and chief compliance officer for a nationwide provider. In 2012, Cat became a consultant and has assisted multiple organizations with their compliance and quality efforts, from program assessment to full program development and implementation. Cat has served as a compliance consultant for a large organization under a Corporate Integrity Agreement. This multi-year, multi-site project involved assessments of operations, quality of care, and clinical documentation. She has also provided clinical and claim reviews for more than 1,200 records of various providers, many with multiple billing periods. Cat has experience providing guidance and support to providers and their legal counsel during investigations by Zone Program Integrity Contractors, Specialty Medical Review Contractors, Medicaid Integrity Contractors, Medicare Administrative Contractors, and investigations with the Department of Justice and the Office of the Inspector General. She also has extensive experience in due diligence evaluations. Cat is a contributor/reviewer for multiple health care publications by Tina Marrelli, including: Home Care Nursing © 2017, Handbook of Home Care Standards © 2018, Hospice and Palliative Care Handbook © 2018, and A Guide for Caregiving © 2017. She also served as assistant author for The Nurse Managers Survival Guide: Practical Answers to Everyday Questions by Tina Marrelli.
This chapter defines errors, waste, abuse and fraud and gives examples of each. Through better understanding of these definitions, employees will be positioned to recognize opportunities for improvement in their organization.
This chapter reviews the four primary regulations that affect the home care and hospice industry. The False Claims Act will be reviewed including its history and rationale. Anti-Kickback, Stark, and exclusions will also be reviewed to provide clarification so providers and clinicians are better informed and can make good decisions on their day-to-day activities.
This chapter reviews the 7 Elements of an Effective Compliance Program as defined by the Office of the Inspector General (OIG). Understanding these elements will help the clinician look for those resources within their own organizations that can assist them in compliance efforts. Each element is reviewed so the clinician will understand why home health and hospice providers carry out specific activities, such as auditing and monitoring.
This chapter reviews the highest risk areas for a home health and hospice provider. Major risk areas for each provider type are listed and discussed. With this information, the clinician is better able to recognize and proactively report any compliance concerns.
Compliance is not the job of one person or one committee. It is the responsibility of every individual within the organization. This chapter reviews individual responsibilities in reporting a concern and cooperating in an investigation. We will also discuss non-retaliation and what you should expect from your employer.