Business Ethics and Compliance - eLogic Learning · 2015-11-16 · • Corporate Compliance Program • Code of Conduct and Ethics Effective December 1, 2011, this course, in conjunction

Business Ethics and Compliance Corporate Integrity Agreement General Training

Self-Paced Workbook Rev 11.28.2011


© 2011 LHC Group, Inc. All rights reserved. No part of this publication may be reproduced, transmitted, transcribed, stored in a retrieval system, or translated into any language in any form by any means without the written permission of LHC Group, Inc. Published in the USA, Revised November 2011

Contents

OVERVIEW ......................................................................................................................... 1

THE CORPORATE INTEGRITY AGREEMENT ....................................................................... 2

IMPORTANCE OF COMPLIANCE ...................................................................................... 4

COMPLIANCE PROGRAM ELEMENTS............................................................................... 4 LHC Group Compliance and Ethics Program Intent ................................................ 4 LHC Group Compliance and Ethics Program Motto ................................................ 5 Pillars of Excellence and Role of Compliance........................................................... 5

GOVERNMENTAL RESOURCES ......................................................................................... 9 Five Principle Strategies for Healthcare Integrity ....................................................... 9 Healthcare Fraud Prevention and Enforcement Action Team ............................... 9

CODE OF CONDUCT AND ETHICS ................................................................................. 10 Ethical Dilemmas ......................................................................................................... 11 Behavior That is Prohibited ......................................................................................... 12

LAWS AND REGULATIONS .............................................................................................. 15 Description of Certain Important Healthcare Laws ................................................ 15

EXPLANATION OF FRAUD AND ABUSE: ......................................................................... 19

COMPLIANCE RISK AREAS FOR LHC GROUP ............................................................... 20 Summary of Key Compliance Risk Areas and Eligibility Criteria ............................ 20 Home Health Compliance Risk Areas ....................................................................... 20 Hospice Compliance Risk Areas ................................................................................ 23 Hospital Compliance Risk Areas ................................................................................ 24

COMPLIANCE AUDITING AND MONITORING ACTIVITIES ........................................... 27

COMPLIANCE IS EVERYONE’S RESPONSIBILITY ............................................................ 28 Reporting Possible Violations ..................................................................................... 29 Responding to Government Requests ..................................................................... 29 Responding to Requests for Information (ROI) ........................................................ 29

SUMMARY ........................................................................................................................ 30

BIBLIOGRAPHY ................................................................................................................ 30


© 2011, LHC Group. All rights reserved. Page 1 BusEthicsand Compliance CIAGenTrng SPW.docx – Rev 11/11

OVERVIEW The purpose of this course is to ensure ethical conduct and compliance with all applicable laws, regulations and policies and procedures.

Effective December 1, 2011 – This course provides information intended to satisfy the general training requirement under the Company’s Corporate Integrity Agreement (CIA). In this course, you will learn about the CIA between LHC Group and the Office of the Inspector General (OIG) and the training requirements that are part of that agreement. You will also learn how we will continue to demonstrate and monitor our commitment to ethics and compliance. The content in this course is based on established processes and procedures which enable us to provide best-of-class care and services, and act as advocates for our patients by meeting all requirements related to our ethics and compliance program.

TARGET AUDIENCE All LHC Group Employees

APPROXIMATE COMPLETION TIME 1 hour

AUTHORS Josh Proffitt, JD, CHC

Senior Vice President, Chief Compliance Officer

Jeanette Chauvin, MBA, Privacy and Compliance Analyst

OBJECTIVES Upon completion of this activity, the student will be able to:

Describe the Company’s Corporate Integrity Agreement, Related Training and Other Requirements.

Explain the importance of Compliance.

Identify behavior that is prohibited under our Code of Conduct and Ethics.

Identify relevant laws and regulations.

State their main compliance risk areas for our company.

Describe auditing and monitoring activities.

State your role in the corporate compliance program.



THE CORPORATE INTEGRITY AGREEMENT The Corporate Integrity Agreement (CIA) is a five (5) year agreement between the Office of the Inspector General (OIG) and LHC Group in which we agree to comply with certain requirements in order to continue our participation in Medicare, Medicaid or other Federally funded healthcare programs. This agreement aligns with LHC Group’s commitment to provide a best of class ethics and compliance program, and exceptional care and unparalleled service to patients and families who have placed their trust in us. One component of the CIA requires that we clearly demonstrate that all employees, officers, directors, and certain other key constituents within the LHC Group family receive one hour of general training on the following:

• CIA requirements • Corporate Compliance Program • Code of Conduct and Ethics

Effective December 1, 2011, this course, in conjunction with the Company’s Code of Conduct and Ethics document, provides the information intended to satisfy this general training requirement under the CIA.

A second component of the CIA requires that we clearly demonstrate that everyone who is involved in:

• The delivery of home health care or services, and/or, • The preparation or submission of claims for reimbursement for home healthcare from

any Federal Health Care Program

receives two hours of training specific to compliance with the following:

• The Federal Health Care Programs requirements regarding: o Home bound status o Medical necessity o Accurate coding and submission of home health claims o Reimbursement

• Policies, procedures, and other requirements for documentation of medical records • Applicable reimbursement statutes & regulations • Legal sanctions for violation of the Federal Health Care Program requirements • Examples of proper and improper claims submission practices • Employees’ individual roles, responsibilities and obligations relative to service provision,

documentation, and claims accuracy and submission

Unless you are brand new to the Company, you have probably already received training on most of these processes and procedures. However, “completing the training” and applying and documenting what you have learned “always” – are two different things. In our environment compliance with doing the right thing is mandatory, and documenting that you did the right thing is “always mandatory” because only you and your patient are witnessing



that it is happening. An added bonus of completing this training is that we will meet the mandatory training requirement as outlined in the CIA. To meet this requirement you must successfully complete the following course content in LHC Connect:

All Employees/All Business Lines: General Training Requirement:

Business Ethics and Compliance: Corporate Integrity Agreement General Training Code of Conduct and Ethics

Specific Home Health and Home Office Training Requirement:

Introduction to Home Care Eligibility: Corporate Integrity Agreement Specific Training Corporate Integrity Agreement Specific Training: Partnering for Excellence

To demonstrate how serious we are about doing the right thing every employee must complete the required training in order to continue working with the LHC Group family. Any employee who fails to complete the training will be terminated. Every new employee must complete the training within 60 days of hire. All employees, both old and new, must also complete this training annually.

In addition to these training requirements, the Corporate Integrity Agreement also requires that LHC Group:

• Maintains a Compliance Officer and Compliance Committee • Maintains Board of Director oversight over the Compliance Officer and Compliance

Committee • Maintains a Code of Conduct and Ethics and requires that every officer and employee

receive, read, understand and attest to abiding by the Code of Conduct and Ethics • Maintains written Compliance and Ethics policies and procedures • Provides Board of Director compliance training • Engages an independent review organization (IRO) to perform the claims reviews and

internal compliance audit reviews annually • Maintains a disclosure program, including our toll-free Integrityline compliance hotline • Performs OIG exclusion screening to ensure all prospective and current employees,

officers, directors, and certain other key constituents within the LHC Group family are not deemed “ineligible persons”

• Ensures all identified overpayments are repaid to the Federal Health Care program no later than 30 days after identification of the overpayment

• Reports certain events identified in the CIA as “reportable events” • Reports certain changes, closures, purchases, or sales of any business unit or location • Issues an implementation report as well as an annual report to the OIG



IMPORTANCE OF COMPLIANCE The LHC Group Compliance and Ethics Program emphasize legal and regulatory requirements. The focus of our Compliance and Ethics Program includes:

• Regulations related to the federal False Claims Act, Stark Law, Anti-Kickback Law, HIPAA Laws and regulations;

• Regulations around inappropriate billing; • Overall adherence to other applicable healthcare regulations; • Following applicable Industry standards; and • Following the standards set forth in our Code of Conduct and Ethics and our policies

and procedures.

Our Code of Conduct and Ethics and programs, policies and procedures support and improve overall compliance within our organization.

COMPLIANCE PROGRAM ELEMENTS An effective compliance program includes actions to prevent and detect illegal, unethical or inappropriate conduct. The Company must promote a culture that encourages ethical conduct. The Company must also make a commitment to obey the law. The seven elements of an effective compliance program are listed below:

1. Written policies, procedures and standards of conduct 2. Designation of a Compliance Officer and Compliance Committee 3. Effective Training and Education 4. Reporting and investigating with effective lines of communication 5. Well-publicized disciplinary guidelines and consistent enforcement 6. Strong monitoring and auditing program 7. Prompt responses to detected offenses and prevention of offenses in the future

LHC Group Compliance and Ethics Program Intent LHC Group’s Compliance and Ethics Program is here to serve you. Our program was developed with you in mind, and it continues to evolve to meet your needs. We strive to be a resource for every member of the LHC Group Family. Our Code of Conduct and Ethics provides clear instruction on handling day-to-day activities. Please see the Code of Conduct and Ethics section of this self-paced workbook for more details. Our Compliance and Ethics Program also provides educational opportunities, such as companywide and role-specific training sessions.

LHC Group’s Compliance and Ethics program encourages supervision and involvement by everyone. Ethical behavior should be the foundation of every decision you make. Compliance is everyone’s job. Written policies and procedures are in place to assist you. These policies may



be accessed through LHC Connect in the Division: LHC Admin Policy Manual, Chapter 6 on Corporate Compliance.

The Compliance Department has clinical and non-clinical staff ready to answer questions and provide guidance. Our Chief Compliance Officer is also available to answer your questions.

LHC Group’s Compliance and Ethics program will help you be aware of, prevent, and monitor compliance issues. The compliance department conducts routine audits and non-routine, unscheduled audits. Please see the compliance auditing and monitoring section of this self-paced workbook for a brief description of our compliance auditing and monitoring program. Our compliance department aims to detect and reduce compliance risks within the Company.

LHC Group Compliance and Ethics Program Motto The motto of LHC Group’s Compliance and Ethics Program is “It’s All About Integrity…” Dictionary.com defines integrity as “adherence to moral and ethical principles; soundness of moral character; honesty.”

Pillars of Excellence and Role of Compliance The goals of our Compliance and Ethics Program tie in with each of LHC Groups’ Six Pillars of Excellence. Compliance activities are part of many business areas. Compliance activities are embedded in each of the following Pillars:

People The compliance department supports all employees. All employees are provided with the anonymous and confidential way to raise questions and concerns through the IntegrityLine compliance hotline. In doing so, we enforce our zero tolerance policy for retaliation. We also provide compliance training and education to all employees through mandatory training, quarterly newsletters and other communications.

Service The compliance department serves as a resource and provides support to all employees. Our goal is to always exceed service expectations. We also serve as an industry-wide compliance resource for home care and hospice. Our department openly shares our experience and compliance knowledge.

Quality The compliance department supports LHC Group’s quality initiatives through ongoing education, monthly auditing and monitoring activities and monthly performance improvement indicator follow-up audits. We intend for these activities to assist in raising our internal and external quality scores and improving patient care and outcomes.

“Integrity is doing the right thing, even if nobody is watching.” – Jim Stovall (You Don't Have to Be Blind to See)



Finance The compliance department supports the Finance Pillar by detecting and responding to potential internal and external financial risks. Through our compliance activities, LHC Group is able to proactively prevent and reduce our risk of penalties or fines that may result from the submission of inaccurate claims, kickbacks and violations of other applicable laws and regulations.

Growth The compliance department supports organic growth activities and growth through acquisitions. For acquisitions, we perform medical record audits and other due diligence activities. We also provide support to the clinical resource teams by ensuring that newly acquired agencies are familiar with LHC Group’s Compliance and Ethics Program and Code of Conduct and Ethics.

Ethics The compliance department supports the LHC Group culture of ethics and always doing the right thing without exception. We ensure that all employees receive and understand our Code of Conduct and Ethics. Through our many compliance activities and communications we also strive to ensure that each employee conducts themselves with the highest standards of ethics and integrity.

•To do the right thing without exception.

LHC Group Ethics Pillar Vision Statement:

•We believe that ethical behavior is at the core of everything we do and resonates throughout our entire organization. We conduct ourselves with the highest standards of ethics, integrity and professionalism.

LHC Group Ethics Pillar Core Value:



E X E R C I S E 1 - P A R T S O F T H E C O M P L I A N C E P R O G R A M List at least five (5) elements of the Company’s compliance program.



E X E R C I S E 1 - A N S W E R K E Y Some – but not all – of the possible answers are listed below.

1. Code of Conduct and Ethics

2. Written policies and procedures

3. Designation of a Chief Compliance Officer

4. Compliance training programs for all employees

5. An anonymous process, such as a hotline, to receive compliance concerns

6. A system to respond to allegations of improper/ illegal activities and the enforcement of appropriate disciplinary action

7. Use of auditing and monitoring

8. Reporting and investigating with effective lines of communication

9. Disciplinary guidelines and consistent enforcement

10. Prompt responses to detected offenses and prevention of offenses in the future



GOVERNMENTAL RESOURCES Many governmental resources focus on detecting fraud, waste and abuse within the healthcare industry. Enforcing compliance in the healthcare industry is a priority of the government. It is a priority because of the potential for fraud and abuse, and the return of funds improperly received by providers to the government. The government does not only ensure compliance. They also ensure patient care is not compromised by improper financial agreements. The government has put in place the following resources to detect fraud, waste and abuse.

Five Principle Strategies for Healthcare Integrity The Office of Inspector General (OIG) uses five strategies to prevent healthcare fraud, waste and abuse.

Healthcare Fraud Prevention and Enforcement Action Team In May 2009, the Department of Justice (DOJ) and Health and Human Services announced the creation of the Healthcare Fraud Prevention and Enforcement Action Team (HEAT). The HEAT makes fighting Medicare fraud a Cabinet-level priority for Health and Human Services and the Department of Justice. As part of the HEAT initiative, Medicare Strike Forces expanded. Medicare Fraud Strike Forces include teams from the following:

• DOJ’s Criminal Division and U.S. Attorneys’ Offices • FBI • CMS • HHS’s Office of the Inspector General

As of February 1, 2011, Medicare Fraud Strike Forces have location sites in South Florida, Los Angeles, Houston, Detroit, Brooklyn, Baton Rouge and Tampa.

• Enrollment: Scrutinize provider applicants1

• Payment: Use reasonable, responsive methods2

• Compliance: Assist providers to comply3

• Oversight: Monitor for fraud, waste, abuse4

• Response: Punish fraud, remedy vulnerabilities5



The Mission of HEAT is as follows: to marshal significant resources across governmental agencies to prevent waste, fraud and abuse in the Medicare and Medicaid programs and crack down on the fraud perpetrators who are abusing the system and costing us all billions of dollars, to reduce skyrocketing healthcare costs and improve the quality of care by ridding the system of perpetrators who are preying on Medicare and Medicaid beneficiaries, to highlight best practices by providers and public sector employees who are dedicated to ending waste, fraud and abuse in Medicare, to build upon existing partnerships that already exist between the Department of Justice and the Department of Health and Human Services like our Medicare Fraud Strike Forces to reduce fraud and recover taxpayer dollars.

Since announcing HEAT in May 2009, the Medicare Fraud Strike Forces have charged 465 defendants with defrauding Medicare of more than $830 million taxpayer dollars.

In addition to the HEAT and Medicare Fraud Strike Forces, the following are other governmental programs focused on detecting and reducing healthcare fraud, waste and abuse:

• Certain Federal Programs: Recovery Audit Contractors (RACs) and Zone Program Integrity Contractors (ZPICs).

• Certain State Programs: Medicaid Integrity Program (MIPs) and Medicaid Fraud Control Units (MFCUs).

CODE OF CONDUCT AND ETHICS Every member of the LHC Group Family must do their job with the highest level of ethics, integrity and professionalism. This also applies to those who provide services for us, including employees, officers, contractors and agents. You must:

Obey federal, state and local laws Comply with federal and state healthcare program requirements Follow LHC Group’s policies and procedures Commit to reporting any compliance concerns

and/or possible violations

LHC Group depends on its employees to use only legal and ethical competitive practices. You should avoid any illegal or unethical activity. Our Code of Conduct and Ethics requires that you behave in a way that helps the organization keep a good reputation in the communities we serve. You must follow federal and state regulations for fraud, waste and abuse.



You are required to read the Code of Conduct and Ethics. You must follow the Code in your daily activities. You are required to sign the Code when you are hired and then annually after that. This signature is an electronic signature. Our compliance software, Compliance360, records it. Your signature is not recorded by LHC Connect.

Read LHC policy number 6.1.016 for more details on our Code of Conduct and Ethics. If you have questions about signing the Code of Conduct and Ethics, contact Jeanette Toups Chauvin, Privacy and Compliance Analyst, at 337-769-0702 or by e-mail at [email protected].

Ethical Dilemmas Ethical dilemmas happen when:

• There is a problem with no satisfactory solution • A choice must be made between two unsatisfactory alternatives • A choice must be made between two opposing ethical principles

Ethical dilemmas often occur in the workplace. The statistics below are about ethical dilemmas in the workplace.

Despite these figures, 78% of employees state their companies clearly explained what they considered ethical and unethical behavior in their workplace. If you experience an ethical dilemma, you must be able to make the right choice. The standards in our Code of Conduct and Ethics are mandatory.

31% of US workers have witnessed co-workers engaging in ethical misconduct

33% of workers in public companies witness ethical misconduct

52% of those witnessing unethical or illegal acts reported it to anyone in authority

65% of employees do not report wrongdoing

68% fear retribution from their manager

81% fear corrective action would be taken

96% fear being accused of not being a team player

mailto:[email protected]�



Behavior That is Prohibited This table gives a list of behaviors that are not allowed under our Code of Conduct and Ethics.

Behavior that is prohibited under our Code of Conduct and Ethics:

Billing for services that are not medically necessary

Buying or selling LHC Group stock based on non-public information

Contracting with, employing or billing services rendered by an individual or entity that is excluded or ineligible to participate in federal health programs

Destroying company records beyond what the company policy allows

Disclosure of non-public company information

Discussing with competitors non-public topics

Disregarding company policies and procedures

Distinguishing the availability of our services or the quality of care provided to our patients

Engaging in activity that is a conflict of interest for LHC Group

Falsification of clinical documentation

Falsification of mileage

Falsification of timesheets

Improper billing of services

Inappropriately accessing patient health information without a need for the information

Inappropriately disclosing patient health information

Making any employment-related decisions based on race, color, religion, gender ethnicity, sexual orientation, age or disability

Offering or paying a referral source anything in exchange for a referral

Reporting to work under the influence of alcohol or drugs

Retaliation

Sexual harassment or any other form of harassment

Use of LHC Group funds or resources directly for a political campaign or political party

Using company property for personal use without supervisory approval



E X E R C I S E 2 – O U R C O D E O F C O N D U C T A N D E T H I C S Read the following scenarios and determine if the employees’ actions are prohibited under our Code of Conduct and Ethics. If the conduct is prohibited, underline (Not Allowed), if the conduct is not prohibited, underline (Allowed)

Scenario 1

Lisa Nurse leaves a patient’s home without getting the patient to sign for the visit. Lisa notices her mistake later in the day and signs for the patient. She will inform the patient of her error at the next visit.

Not Allowed Allowed

Scenario 2

Bob Billings is completing his timesheet and notices that he has one-hundred and forty-seven (147) business related miles. He rounds the total to one-hundred and fifty miles (150). He always rounds his miles up or down to the nearest tenth. For example, he records 32 miles as 30 miles, and 36 miles as 40 miles.

Not Allowed Allowed

Scenario 3

Cathy Chatty is in a meeting and finds out that our company is on the verge of a major upgrade in technology. This will possibly give us a major edge over our competition. During the meeting, it is stated that this information will be released at the end of the month. Cathy goes back to her desk and calls her sister to tell her the good news.

Not Allowed Allowed

Scenario 4

Wanda Wife is at work when her husband calls to remind her to drop off a letter to the bank. Wanda wrote the letter at home last night but forgot to bring it with her. There is no way that she could go home, pick up the letter and make it to the bank in time. She asks her manager if she could use her company computer to type the letter during her lunch break. Her manager says yes. Wanda types her letter during her personal lunchtime and makes it to the bank in time.

Not Allowed Allowed



E X E R C I S E 2 – A N S W E R K E Y Scenario 1

Lisa Nurse leaves a patient’s home without getting the patient to sign for the visit. Lisa notices her mistake later in the day and signs for the patient. She will inform the patient of her error at the next visit.

Not Allowed Allowed

Lisa’s action is considered falsification of clinical documentation and therefore is prohibited!

Scenario 2

Bob Billings is completing his timesheet and notices that he has one-hundred and forty-seven (147) business related miles. He rounds the total to one-hundred and fifty miles (150). He always rounds his miles up or down to the nearest tenth. For example, he records 32 miles as 30 miles, and 36 miles as 40 miles.

Not Allowed Allowed

Bob’s action is considered falsification of time sheets and therefore is prohibited!

Scenario 3

Cathy Chatty is in a meeting and finds out that our company is on the verge of a major upgrade in technology. This will possibly give us major edge over our competition. During the meeting, it is stated that this information will be release at the end of the month. Cathy goes back to her desk and calls her sister to tell her the good news.

Not Allowed Allowed

Cathy’s action is considered disclosure of non-public company information and therefore is prohibited!

Scenario 4

Wanda Wife is at work when her husband calls to remind her to drop off a letter to the bank. Wanda wrote the letter at home last night but forgot to bring it with her. There is no way that she could go home, pick up the letter and make it to the bank in time. She asks her manager if she could use her company computer to type the letter during her lunch break. Her manager says yes. Wanda types her letter during her personal lunchtime and makes it to the bank in time.

Not Allowed Allowed

Wanda did the right thing by asking for permission to use company equipment for personal use.



LAWS AND REGULATIONS Healthcare is a unique industry. It has strict standards and special regulations. In the United States, healthcare laws attempt to reduce fraud, waste and abuse. The laws aim to prevent financial motives from influencing medical judgment. The laws seek to protect patients. Our government strives to improve the quality of healthcare and to reduce the cost of healthcare.

Below is a very brief description of certain important healthcare laws. If you have any questions about these laws, contact our General Counsel or our Chief Compliance Officer.

Description of Certain Important Healthcare Laws False Claims Act The False Claims Act is a federal law. It covers fraud involving any federally funded contract or program. These programs include Medicare and Medicaid. The False Claims Act establishes liability for any person who presents a false claim to the U.S. government for payment. The False Claims Act does not require proof of a specific intent to defraud the U.S. government. Providers can be prosecuted for a wide variety of conduct that leads to the submission of false claims. Such conduct includes:

• Knowingly making false statements • Falsifying records • Double-billing for items or services • Submitting bills for services never performed or items never furnished

The potential penalties for violating the False Claims Act are severe. The penalties include:

• Civil and monetary penalties ranging from $5,500 to $11,000 per claim • Criminal prosecution, including imprisonment • Exclusion from federal healthcare programs

The False Claims Act includes a “qui tam” or whistleblower provision. This is to encourage people to come forward and report wrongdoing. This provision lets any person who knows about a submission of false claims to the government to file a lawsuit on behalf of the U.S. government.

Deficit Reduction Act The Deficit Reduction Act (DRA) of 2005 lets states keep 10% of any amount recovered through false claims. The DRA applies to any state that enacted its own False Claims Act that was comparable to the federal statute. As of 2010, the following states have a state-level False Claims Act that meets the DRA requirements: California, Georgia, Hawaii, Illinois, Indiana,



Massachusetts, Michigan, Nevada, New York, Oklahoma, Rhode Island, Tennessee, Texas, Virginia and Wisconsin.

Health Insurance Portability and Accountability Act The Health Insurance Portability and Accountability Act (HIPAA) is a federal law. HIPAA governs the protection of patient confidentiality, security of electronic systems, and standards and requirements for electronic transmission of health information. HIPAA has three parts relevant to healthcare information:

• Requirements related to privacy of individually identifiable health information • Security of electronic health information • Standardization of transactions and code sets

HIPAA regulations are enforced by the Department of Health and Human Services, Office of Civil Rights.

The potential penalties for violating HIPAA regulations are also severe and include the following:

• $100-$25,000-if violation was not known • $1,000 to $100,000-due to reasonable cause and not to willful neglect • $10,000 to $250,000-violation due to willful neglect, but is corrected • $50,000 to $1,500, 000-violation due to willful neglect and is not corrected

Questions regarding HIPAA and any other privacy or security questions can be directed to Kathy Boone, RHIA – Privacy and Security Officer or Jeannette Toups Chavin, MBA – Privacy and Compliance Analyst at 337-233-1307 or via email at [email protected]. The HIPAA Privacy and Security self-paced workbook is also available on LHC Connect for your reference.

Anti-Kickback Law The Anti-kickback Law applies to anyone, from healthcare providers to individuals, including our employees. The Anti-kickback Law applies to any items or services reimbursed or paid by Medicare, Medicaid and other federal healthcare programs. This includes services offered by LHC Group and its affiliates. These services include home health, hospice and hospital services that are reimbursed or paid by Medicare, Medicaid or federal healthcare payers. The Anti-Kickback Law is violated when a referral source receives something of value in exchange for or to induce past, present, or future patient referrals. Violation of the Anti-kickback Law will affect the referring physician, LHC Group and the individual involved with offering or giving something of value. There are certain safe harbor regulations that will protect parties from potential violations of the Anti-Kickback Law.




The potential penalties for violating the Anti-Kickback Law include:

• $50,000 civil monetary penalty per violation • Criminal penalties of up to $25,000 in fines and/or up to 5 years in jail • Exclusion from federal healthcare programs

Stark Law The Stark Law is also referred to as the Physician Self-Referral Law. Under this law, physicians are prohibited from referring Medicare patients for certain designated health services (DHS) to an organization with which the physician or member of the physician’s immediate family has a financial relationship unless an exception exists. The Stark Law also prohibits an entity from presenting (or causing to be presented) a bill or claim to anyone for a DHS furnished as a result of a prohibited referral.

The statutory and regulatory exceptions are the key to compliance with the Stark Law. Any financial relationship between a provider and a physician who refers to the provider must fit into an exception and meet all conditions set forth in the exception.

The potential penalties for violating the Stark Law are severe and include:

• $10,000 for each failure to report when required by statute • $15,000 for each item or service subject to improper referral • $100,000 for each circumvention scheme • Exclusion from federal healthcare programs • Possible False Claims Act Liability

LHC Group has developed a specific policy about the Anti-Kickback Law and Stark Law. Please refer to policy number 6.2.001, Code of Conduct for Sales, Marketing, Education and Entertainment Activities with Physicians and Other Healthcare Professionals for more details. This policy applies to all LHC Group employees (not just the sales force).



E X E R C I S E 3 – L A W S A N D R E G U L A T I O N S Below is a list of healthcare laws and regulations and a list of descriptions. Draw a line to match each law or regulation on the left with its corresponding description on the right.

Deficit Reduction Act

Health Insurance Portability and Accountability Act

Anti-Kickback Law

Stark Law

False Claims Act

Cannot give referral sources something of value in return for referrals

Physicians cannot refer patients to a business for which they have a financial interest unless an exception exists

Billing for services not provided

Allows the states to keep 10 % of any money recovered through false claims

Protects patient confidentiality



E X E R C I S E 3 – A N S W E R K E Y Below is a list of healthcare laws and regulations and a list of descriptions. Draw a line to match each law or regulation on the left with its corresponding description on the right.

EXPLANATION OF FRAUD AND ABUSE: Fraudulent activity is an action that is done for one’s own benefit or for the benefit of another. This activity can be knowing, willful, reckless or unintentional. Fraudulent activity may involve false statements or representations of facts in order to obtain payment or other benefit. Abuse involves practices that result in unnecessary increased costs or use of medical services/products.

Examples of Fraud and Abuse:

• Billing for services not provided • Billing for services that are not medically necessary • Billing for services not properly documented • Falsifying a cost report • Offering, giving, soliciting or receiving anything of value for a patient referral • Substandard quality of care • Restriction of patient choice

Deficit Reduction Act

Health Insurance Portability and Accountability Act

Anti-Kickback Laws

Stark Law

False Claims Act

Cannot give referral sources something of value in return for referrals

Physicians cannot refer patients to a business for which they have a financial interest unless an exception exists

Billing for services not provided

Allows the states to keep 10% of any money recovered through false claims

Protects patient confidentiality



COMPLIANCE RISK AREAS FOR LHC GROUP Summary of Key Compliance Risk Areas and Eligibility Criteria LHC Group operates in a complex regulatory environment. We are exposed to different kinds of compliance-related risks. Our Compliance and Ethics Program is designed to focus on the areas of risk that result from our participation in federally and state funded healthcare programs. The following is a list of risk areas that are primarily addressed through our Compliance and Ethics Program. This list is not all-inclusive.

• Submission of accurate claims and the federal False Claims Act • Risks and red flags identified by the Office of Inspector General and other

governmental authorities • HIPAA Privacy and Security rules • The referral-based statutes listed in the Physician Self-Referral Law (i.e., Stark Law) • The federal Anti-Kickback Law

LHC Group only admits and cares for patients who meet the eligibility criteria of the payer source for our services. There are significant risks related to not following eligibility criteria. All decisions should be made based on what is best for the patient. Decisions should not be made for any other reason.

Home Health Compliance Risk Areas The following Compliance-related risk areas for home health agencies are identified by the Office of Inspector General (OIG):

Fiscal Year 2012 OIG Work Plan Risk Areas

•Home Health Agency Claims Compliance with Coverage and Coding Requirements•Home Health Prospective Payment System Requirements•Home Health Agency Trends in Revenue and Expenses•Oversight of Home Health Agency Outcome and Assessment Information Set Data•States' Survey & Certification of Home Health Agencies•Medicare Administrative Contractors Oversight of Home Health Agency Claims•Wage Indexes Used to Calculate Home Health Payments•Missing or Incorrect Patient Outcome and Assessment Data•Questionable Billing Characteristics of Home Health Services




•Part B Payments for Home Health Beneficiaries•Home Health Prospective Payment System Controls•Home Health Agency Profitability•Home Health Agency claims for Medicare Home Health Resource Groups•Medicare Home Health Agency Enrollment•Oversight of Home Health Agency Outcome and Assessment Information Set Data

Fiscal Year 2010 OIG Work Plan Risk Areas •Part B payments for Home Health Beneficiaries•Prospective Payment System Controls•Outlier Payments•Home Health Agency Profitability•Medicare Home Health Payments for insulin injections•Accuratley coding claims for Medicare Home Health Resource Groups•Medicare Home Health payments for diabetes self management trainig services•Oversight of Home Health Agency outcome and assessment inforamtion data set



Other Compliance Related Key Risk Areas for Home Health Agencies include:

Billing for Medically Unnecessary Services

Billing for Services Not Actually Rendered

Billing for Services for Patients who are not Homebound

Disregard for Available, Willing and Able Caregivers when Providing Services

Over utilization and under-utilization

Failure to comply with new therapy coverage assessment and documentation requirements

Manipulation of the Various Therapy Thresholds

Failure to follow Conditions of Participation

Complete understanding and application of Oasis-C Requirements

Inappropriate Length of Stay

Episodes with Exactly Five Visits to Inappropriately Avoid a LUPA

Failure to comply with the new Face-to-Face Encounter Requirements

Inadequate Clinical Documentation

Relationships with Potential Referral Sources

Sales and Marketing Efforts and the Anti-Kickback Statute

HIPAA and other Privacy and Security Risks

Medicare Home Health Eligibility

We MUST ALWAYS certify the following on EVERY Medicare Home Health Patient on our Census:

• That the Patient is Homebound. • That the care is authorized by an Eligible Physician. • That we are providing a Skilled Qualifying Service. • That the care is Reasonable and Medically Necessary. • That the care is provided on an Intermittent Basis.

We MUST ALWAYS complete the Eligibility Criteria Checklist on EVERY admission and recertification.

A willing, able and available caregiver is a family member or other person that has agreed to provide those services that can be performed to meet the patient’s needs. If there is such a person, Home Health will not perform these services or bill for the services that are provided by the caregiver.



Hospice Compliance Risk Areas The following Compliance-related risk areas for Hospice Agencies are identified by the Office of Inspector General (OIG):

Other Key Compliance Related Risk Areas for Hospice Agencies include:


Billing for Services Not Actually Rendered

Inadequate Clinical Documentation

Improper Relinquishment of Core Services

Uninformed Consent to Elect Medicare Hospice Benefit

Patients Receiving Greater than Six Consecutive Months of Services

Admitting Patients who are not Terminally ill

Failure to comply with new Face –to- Face Encounter Requirements

Failure to Follow Conditions of Participation




Fiscal Year 2012 OIG Work Plan Risk Areas•Hospice Marketing Practices and Financial Relationships with Nursing Facilities •Medicare Hospice General Inpatient Care


•Hospice Utilzation in Nursing Facilities•Services provided to Hospice Beneficiaries Residing in Nursing Facilities

Fiscal Year 2010 OIG Work Plan Risk Areas •Physician Billing for Medicare Hospice Beneficiaries•Trends in Medicare Hospice Utilization



Hospice Medicare Eligibility

We MUST ALWAYS certify the following on EVERY Medicare Hospice Patient on our Census:

• Objective Documentation present to support the terminal diagnosis of the patient and that the patient is expected to have a life expectancy of six months or less if the disease follows the normal course

• Documentation is present that shows the patient has the desire for palliative, non-curative treatment (signed election statement)

• Admission to Hospice occurs only with certification of terminal illness by the patient’s Attending Physician (if any) and the Hospice Medical Director

• Services are provided under a written Plan of Care that is established and reviewed by the Hospice Interdisciplinary Group as needed but at least every 15 days. The Hospice Plan of Care must identify the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care.

• Care and services provided on a 24-hour, continuous basis by a nurse or a hospice aide only occur during periods of crisis and only as needed to maintain the terminally ill patient at home.

Hospital Compliance Risk Areas The following Compliance-related risk areas for Hospitals are identified by the Office of Inspector General (OIG):


•Hospital Claims with High or Excessive Payments•Hospital Inpatient Outlier Payment: Trends and Hospital Characteristics•Hospital Same Day Readmissions•Hospital Admissions with Conditions Coded Present-on-Admission•Hospital Reporting for Adverse Events•Reliability of Hospital-Reported Quality Measure Data•Medicare Payments for Beneficiaries with Other Insurance Coverage•Accuracy of Present-on-Admission Indicators Submitted on Medicare Claims•Medicare Inpatient and Outpatient Payments to Acute Care Hospitals•Medicare's Reconciliations of Outlier Payments•Acute-Care Hospital Inpatient Transfers to Inpatient Hospice Care•Hospital Occupational-Mix Data Used to Calculate Inpatient Hospital Wage Indexes



Other Compliance Related Key Risk Areas for Hospitals include:


Billing for Services not Actually Rendered

Substandard Quality of Care

Inappropriate Length of Stay

Illegible Physician Signatures



Physician Signatures on Lab Requisition Forms


Fiscal Year 2011 OIG Work Plan Risk Areas •Work Plan Medicare Excessive Payments•Hospital Inpatient Outlier Payments•Hospital Readmissions•Hospital Admissions with Conditions Coded Present-on-Admission•Early Implementation of Medicare policy for Hospital-Acquired Conditions•Hospital Reporting for Adverse Events•Hospital Reporting for Restraint-and-Seclusion-Related Deaths•Medicare Secondary Payer/Other Insurance Coverage

Fiscal Year 2010 OIG Work Plan Risk Areas •Hospital Coding and Documentation under MS-DRG’s•Adverse Events•Hospital Readmissions•Hospital Admissions with Comditions Coded Present-on-Admission



Hospital Eligibility Currently Medicare does not have eligibility requirements defined for LTACHs.

Fundamental Principles of LTACH eligibility include:

• Services can’t be provided in a lower level of care • Patient has a reasonable chance for improvement • The care is medically necessary • Patients must receive interdisciplinary team treatment

Ensure clinical documentation supports admission to the LTACH.

E X E R C I S E 4 – R I S K S A N D P E N A L T I E S In this section, you will identify the potential compliance-related risks for your job and the tasks for which you are responsible.

Circle the business line that you work for: Home Health Hospice LTACH (Hospital)

Based on your job and responsibilities list at least three compliance related risk areas:

1.

2.

3.

4.



E X E R C I S E 4 – A N S W E R K E Y

In this section, you will identify the potential compliance related risks for your job and the tasks for which you are responsible.

Circle the business line that you work for: Home Health Hospice LTACH (Hospital)

Based on your job and responsibilities list at least three compliance related risk areas:

You response in this section will vary depending on your role and responsibilities.

You should review and discuss this exercise with your manager to ensure that you understand your role in eliminating compliance risks.

COMPLIANCE AUDITING AND MONITORING ACTIVITIES The Compliance Department promotes compliance with healthcare regulations and policy. The Compliance Department assesses risk and oversees companywide compliance risk mitigation.

Auditing and monitoring are two separate activities. Auditing is an independent overview function that is separate from an operational or business function. The compliance and internal audit departments as well as certain independent third party vendors complete LHC Group’s auditing functions. LHC Group’s monitoring is conducted by our quality, performance improvement and operations teams.

An ongoing auditing and monitoring program is maintained to evaluate adherence to LHC Group’s policies and procedures, state and federal laws and regulations. Each year the Office of Inspector General issues a “Work Plan.” This work plan outlines the areas and issues the OIG will focus on during that fiscal year. Please see the prior section of this self-paced workbook, titled Compliance Risk Areas of LHC Group, for lists of specific risks identified by OIG Work Plans.

The OIG Work Plan provides insight into the areas and issues that may evolve into future OIG enforcement activities. LHC Group considers the OIG Work Plan in planning all auditing and monitoring activities. Each area of the Work Plan is assessed for potential impact on the Company’s operations and risk areas. The OIG Work Plan guides the compliance department in creating its own annual auditing work plans. LHC Group’s work plans cover the areas identified by the OIG as critical. Please refer to the Compliance Auditing and Monitoring Policy – Policy number 6.1.009 – for additional information.



Compliance audits are routinely conducted for every aspect of our business, including Home Health, Hospice, Private Duty, Pharmacy and LTACH. These audits are performed at various frequencies. These frequencies include monthly, bi-monthly, quarterly and annually.

COMPLIANCE IS EVERYONE’S RESPONSIBILITY You are expected to know and follow the laws and regulations that affect your job. Compliance and ethics are also a part of job performance. Your actions should reflect the mission of LHC Group. All Company employees must “do the right thing without exception.” Employees are expected to perform duties and responsibilities with integrity.

Failure to follow the guidelines of the Compliance and Ethics Program can result in:

• Disciplinary action • Termination • Criminal prosecution • Monetary fines

Failure to follow the LHC Group Compliance and Ethics Program can also result in LHC Group’s exclusion from federal healthcare programs. If Company employees do not follow our Compliance and Ethics Program, we will lose our reputation for integrity in the communities we serve.

You should not put yourself in a position where your interests will be in conflict with the interests of LHC Group. For examples:

• Having a financial interest in a business that provides supplies or services to or is in competition with LHC Group.

• Accepting a gift that may influence one’s individual judgment in acting on behalf of LHC Group, such as accepting a gift from a medical supply vendor so that all medical supplies are purchased from that company.

Employees are responsible for reporting suspected compliance violations. All employees are required to report activity that appears to be a violation of any of the following:

• Legal or regulatory guidelines • LHC Group Code of Conduct and Ethics • Any policies and procedures

All reported concerns are investigated quickly and confidentially. No disciplinary action or retaliation will be taken against any individual for reporting an issue, problem, concern or violation in good faith. Anyone who retaliates against an individual for reporting a compliance



concern will be subject to disciplinary action, up to and including termination. Please refer to the Compliance Non-Retaliation/Non Retribution Policy (Policy number 6.1.020) for more information.

Reporting Possible Violations Methods to report possible compliance violations include:

• Your supervisor or another manager • The phone or web-based compliance hotline, the IntegrityLine, 1-888-703-0301 or

report online at www.lhcgroupintegrity.com o Employees can call and report compliance issues anonymously to the

IntegrityLine • The Chief Compliance Officer, Josh Proffitt, at (337) 233-1307

What happens after I report a possible compliance violation? An independent third-party company receives all concerns reported to the IntegrityLine, whether the concerns are submitted by telephone or on the Internet. You have the choice to remain nameless or provide your name and contact information. The third- party company provides all reporters with a reference number. The reference number can be used to get resolution details. It can also be used to correspond with the Chief Compliance Officer.

All concerns are sent directly to our Chief Compliance Officer. He personally reviews all concerns and takes whatever actions are needed to respond to the concern. All concerns are taken seriously. Concerns are investigated thoroughly and kept confidential. Depending on the nature of the concern, the investigation may involve members of any combination of compliance, human resources, other management and operations. We encourage you to submit any information, question or concern in good faith about questionable, unethical, or illegal activities within the Company.

Responding to Government Requests All governmental audit requests such as CERT, ADR, 2nd Level, Probe, RAC, MAC, QIC and ZPIC, should be sent to [email protected] or if you have questions about these contact Lori Garza at 337-233-1307 or via email at [email protected]

Responding to Requests for Information (ROI) All requests for access to or for a copy of medical or billing records must be forwarded to the Privacy Office. LHC Group’s Privacy Officer is Kathy Boone. Kathy can be reached at 337-233-1307 or via email at [email protected]. In addition, the HIPAA self paced workbook and all related ROI policies can be found on or through LHC Connect.

http://www.lhcgroupintegrity.com/�






SUMMARY In closing please, remember the following information:

Reach out to the Compliance Department whenever you have a question or need clarification

Report any possible compliance violation via the process described in this training Live by the Code of Conduct and Ethics as proscribed by LHC Group Always do the right thing without exception!

BIBLIOGRAPHY Office of Inspector General – December 3, 2009

Statement of Lewis Morris, Chief Counsel, Office of Inspector General, Department of Health and Human Services before the U.S. Senate Homeland Security and Governmental Affairs Subcommittee on Federal Financial Management, Government Information, Federal Services, and International Security on Eliminating Waste and Fraud in Medicare and Medicaid; April 22, 2009

Daniel Levinson, HHS Inspector General; Integrity and Healthcare Reform: The Charge to Government and Industry Presentation. HCCA 13th Annual Compliance Institute, 4/27/2009

www.stopmedicarefraud.gov/heatsuccess/index.html

www.stopmedicarefraud.gov/

www.cms.gov

Investor Relations Guide Bulletin @2005 Kennedy Information, Inc.

www.oig.hhs.gov/publications/work plan/2011

http://www.stopmedicarefraud.gov/heatsuccess/index.html�

http://www.stopmedicarefraud.gov/�

Documents

Business Ethics and Compliance - eLogic Learning · 2015-11-16 · • Corporate Compliance Program • Code of Conduct and Ethics Effective December 1, 2011, this course, in conjunction