3/16/2016
Compliance in the Country: Considerations for Critical Access and Rural Hospitals
Tomi Hagan, MSN, RN, CHC
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Today’s Presenter
Tomi Hagan, MSN, RN, CHC
Senior Consultant, Compliance
Tomi Hagan has over 10 years of experience in healthcare and business management, with a strong focus on relationship building and the promotion of ethics and compliance. Her areas of expertise include program development and advancement, risk assessment and effectiveness evaluation, auditing and monitoring processes, and education. She has extensive experience in managing a variety of compliance issues, including claims and billing, Stark, HIPAA, conflict of interest, and EMTALA.
Prior to joining Quorum, Tomi served in both clinical and management positions in a variety of healthcare settings. She has a background in rural healthcare along with compliance program management experience at a large system level. Tomi specializes in a customer focused proactive approach to identification of opportunities for improvement and implementation of practical, innovative solutions.
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Objectives
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Interactive discussion about unique compliance challenges in rural and Critical Access Hospitals
Address supervision of outpatient services, specialty clinic considerations, and emergency room transfer concerns proactively to avoid False Claims Act, Stark, and EMTALA liability
Practical guidance and innovative ideas for compliance program implementation and improvement with limited resources
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Challenges
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Compliance Program Challenges
LIMITED RESOURCES
LEADERSHIP BUY‐IN
Compliance is not a revenue‐
generator
Yates Memo
COMPLEX REGULATORY ENVIRONMENT
Where do we start?
ROLE DEFINITION
Compliance, Privacy, Quality, Risk, Patient Safety
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Additional Challenges for CAH/Rural Hospitals
LOWER VOLUME OF ISSUES
OIG WORK PLAN FOCUSES ON PPS
Effect on level of expertise
MULTIPLE HATS
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CULTURE
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What Challenges are You Facing?
• How have these changed over the past few years?
• How has your compliance risk mitigation strategy changed?
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Not All Doom and Gloom!
What do we do well in the country?
 Culture
 Compliance program awareness
 Quality of care
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Specific Risks
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Supervision of Outpatient Diagnostic Services
• Supervision levels in the Medicare Physician Fee Schedule
 https://www.cms.gov/apps/physician‐fee‐
schedule/search/search‐criteria.aspx
 09 indicates does not apply (therapeutic rather than diagnostic)
• Supervision provided by physician
• Applies to services reimbursed under OPPS
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Supervision of Outpatient Therapeutic Services
• Condition of Payment
• Moratorium extension for direct supervision of outpatient therapeutic services enforcement through end of 2015
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Signed by President December 18, 2015
• Physicians only for direct supervision of cardiac and pulmonary rehab
• HOP Panel
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Supervision of Outpatient Therapeutic Services Legislation
• Protecting Access to Rural Therapy Services (PARTS)
 Default supervision level General, with process for exceptions
 S. 257 referred to committee January 27, 2015
 H.R. 1611 referred to committee March 25, 2015
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Supervision of Outpatient Therapeutic Services Legislation
• Amend title XVIII of the Social Security Act to allow physician assistants, nurse practitioners, and clinical nurse specialists to supervise cardiac, intensive cardiac, and pulmonary rehabilitation
S. 488 referred to committee Feb 12, 2015
 H.R. 3355 referred to committee July 29, 2015
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Key Definitions
• Direct Supervision
 “Immediately Available”
• NSEDTS
 Non‐Surgical Extended Duration Therapeutic Service
• General
• Personal
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Are you prepared for enforcement for CAH?
• Plan for coverage
• Documentation considerations
• Policies/procedures
• Education/training for all affected staff
• Monitoring/auditing
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False Claims r/t Supervision Examples
January 2013 Georgia
• $1.2 million settlement
• MRI with contrast
April 2013 N. Carolina
• $2 million settlement
• Administration of IVIG Proprietary & Confidential
March 2015 Florida
• $5.4 million settlement
• Radiation oncology
June 2015
California
• $550,000 settlement
• Radiation therapy
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Specialty Clinics
• Agreements

Billing structure
• Leases
Equipment
 Employees
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• Provider‐based
• Commercially reasonable
• Fair Market Value
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Monitoring & Auditing Specialty Clinic Arrangements
• Physician Payment Reconciliation
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Payments to physicians
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Rents receivables
• Physical audit of space/ equipment in use
• Provider based audit
• Non‐monetary compensation
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Pitfalls
• Expired agreements
 New Stark regulations do provide relief
• Past due rents
• Inaccurate agreements
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Emergency Room Transfers
• Most will be from rural to metro
 Not always – OB may be rural to rural
• Call lists
• Transfer agreements
• MSE and stabilization
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EMTALA Violation Example
Hospital failed to provide an adequate medical screening examination for a 38‐weeks pregnant woman complaining of abdominal and lower back pain
No medical history, vitals, fetal monitoring, tests for fetal movement, or exam on the patient
 Patient left by private vehicle and presented at the emergency department of another hospital where she was admitted and delivered a stillborn baby
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EMTALA Violation Example
Hospital refused to provide pain medication to 65‐year old man who had been shot in the arm Patient arrived at hospital via ambulance to be air lifted. Due to weather, helicopter unable to land.  Patient requested pain relief for his severe pain. As the paramedics unloaded the patient from the ambulance, the emergency department doctor and a nurse came out to the ambulance and refused to let the patient enter the hospital because they did not have a trauma surgeon on staff. Both the paramedic and the patient explained that the patient wanted pain relief for the long trip, but the doctor and nurse returned inside, with locked doors closing behind them.
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EMTALA Violation Example
Hospital failed to provide stabilizing treatment to an 18 year‐old with severe pain and multiple broken bones
Severe pain in his feet, ankles, and right shin after jumping from a twenty foot wall and landing on concrete. Although the hospital had an orthopedic surgeon on call, the emergency room staff did not consult with him nor did they provide treatment for the patient's pain or splint his legs before transferring him to the trauma center.
 Trauma center ultimately did not consider the patient a trauma case.
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EMTALA Violation Example
Hospital refused to accept the appropriate transfer of a 61‐year‐old woman, with a subdural hematoma and needing emergency surgery
ED physician called to make arrangements to transfer the patient, call was transferred the call to its ED, then Hospitalist, and then Neurosurgeon.
 Neurosurgeon responded that it sounded like the patient was brain dead, which the ED physician advised was not the case, and did not accept transfer.
 ED physician then transferred the patient to another hospital where she successfully underwent surgery and was released to a rehabilitation facility five days later.
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EMTALA Violation Example
Hospital failed to evaluate a 72 year old patient's head pain or provide stabilizing treatment Bruising and abrasions on her nose, two black eyes and a skin tear, complained of severe pain in face/head.  Abrasions and skin tear were cleaned and she was discharged home a little over one hour after arrival in the ED.  No diagnostic tests and no treatment for her head pain.
 Medical screening exam upon return to the ED the next morning revealed multiple head fractures. 
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Bottom Line
• Every patient who presents to the emergency department requesting treatment receives a medical screening exam by a qualified medical person
• Stabilizing treatment
• Appropriate transfer
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Privacy/Security Challenges
• “Where everybody knows your name…”
• Employees as patients
• Limited resources
 Access monitoring software versus manual
 Audits may be difficult with some EMR
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Compliance Program
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Structure
• More than one way to skin the compliance cat!
• Collaboration
• Multiple hats
 Which hats fit well with the compliance hat?
 Remember, Compliance Officer must be “well‐qualified” and “member of senior management” according to 2005 OIG Supplemental Compliance Program Guidance for Hospitals
 Appropriate independence
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Compliance Ambassadors
Opportunity to involve staff in developing the culture of compliance
 Front line staff
 Multi‐disciplinary
 NOT the “compliance cops”
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Compliance & Ethics Week
• Can be celebrated on a budget
 Promotional items available through HCCA
• Visibility
• Incentives
 FSG §8B2.1(6)(a) “appropriate incentives to perform in accordance with the compliance and ethics program”
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Culture of Compliance
More or less challenging to cultivate in a smaller or rural facility?
• Fear of reporting
• Not only retaliation, but also fear of offending people
• More opportunities for Compliance Officer “face time”
• Hotline used less frequently in smaller facility
• Good or bad?
• Comfort reporting directly vs fear of reporting at all
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Challenges
Solutions
Understanding complex issues
Network: HCCA, internal sources, legal counsel
Scheduling compliance committee meetings
Piggyback to an existing meeting
Education: Holding audience attention
Simplify with use of relevant examples
Workload: So much to
do, so little time
Identify champions: delegate, teamwork
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