HCCA: Compliance in the Post-Acute Environment

On Sunday morning, I attended the session “Compliance in the Post-Acute Environment”. Given that MD Ranger serves an increasing number of these types of organizations, I looked forward to learning more about compliance in this particular space.

The speakers first tackled the tough reality that, while compliance programs for post acute facilities have been mandated by ACA, we still don’t know the specific requirements of these programs. This presentation addressed how compliance officers in the post acute world can “predict” what the OIG and CMS will care about, and structure their compliance program and procedures accordingly.

Overall, it’s safe to say that many elements of an acute care organization’s compliance program translate on the post acute care side of the industry. The speakers emphasized the importance of an easy to understand code of conduct (or compliance policies), as well as a compliance officer that has the resources and authority to do her job. Sanction screening, internal monitoring, enforcement, and measures to address non-compliance were all important elements of post acute compliance programs.

Despite the fact that a lesser number of physicians are involved in post acute care, the speakers took care to mention that a thorough review of your physician contracts is essential to preventing risks like AKB violations or Stark violations. Reviewing agreements with all referral sources can help you document your compliance with federal regulations and ensure that all contracts are fair market value. Integrating physician agreements with your formal compliance program is key.  From our perspective at MD Ranger, we couldn’t have said it better ourselves. Because post acute care organizations are so heavily dependent on referrals from key physicians, documentation of FMV becomes even more critical.

Post acute organizations:  how do you handle physician contract auditing at your facilities?


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Key Elements of Physician Contracting Compliance Programs

Because each organization is different, there are hundreds of ways to operationalize a well functioning compliance team.  No compliance program is “one size fits all”.  However, we’ve found that successful compliance programs do have a few things in common.

Here are five key elements that every physician contracting program should address:

  • Executive oversight:  make sure your program has an executive champion and that she’s empowered to make decision for her team.
  • Contract management:  have a rigorous contract management system that is well-defined and includes processes like renewal management, contract organization, and exceptions handling.
  • Financial oversight:  ensure that your contracts are commercially reasonable and keep tabs on overall physician spending.
  • Compliance management:  invest in educating your team and determine how you’re going to document FMV.
  • Rigorous, consistent process for determining FMV:  decide which method to use, and stick with the system you create.


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Hot, Actionable Compliance Tips

How does your organization ensure that its financial relationships with physicians are compliant with federal regulations? Here are just a few tips to help you get started today.

1. Is your organization fully aware of Stark Law and Anti-Kickback statutes, as well as the fines and penalties for non-compliance?

Many organizations we find who are non-compliant with federal regulations aren’t aware of the severe penalties. Physicians themselves hold considerable risks, both financial and to their reputation. However, given hospital’s reliance on CMS, the penalties can have a huge impact. Sanctions for hospitals violating Stark law include inability to bill to CMS, refunding payments (up to three times the amount of the initial payment), and denial of payments. Audits can be extremely costly to an organization and will run into the millions of dollars for penalties and fees. In early 2013, Intermountain Healthcare paid a $25 million settlement involving 209 physicians.  In 2012, HCA settled a case involving imaging referrals for $16.5 million.

2. Does your organization have contracts for all contracted services/positions?

It’s important to document all financial arrangements with physicians. This is easier said than done, especially when it comes to contracting for call coverage or medical directorships. Work with administrators and chiefs of staff to ensure that all contracted positions are well-documented and contracted, with payment rates and expiration dates clearly articulated.

3. Do you track or automate contract expiration dates?

When organizations deal with hundreds of contracts that renew throughout the year, keeping organized is critical for successful and timely renegotiations. If your organization doesn’t have a contract management system built internally or contracted externally, obtain or create one. Automate the process of renegotiation once a contract is three or six months from expiration, and decide on a consistent process for addressing and executing renewals.

For more compliance tips, check out our Compliance Risk Checklist.

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Key Considerations for Pediatric Hospitalist Agreements

These contracts provide for pediatric hospitalist services, most frequently provided by board-certified  pediatricians. The contracts provide physician staffing for dedicated programs in which at least one physician is available or on-call at all times to:

  • Provide general attending coverage for pediatric inpatients
  • Serve patients who require a consultation or admission, and who do not have a primary pediatrician or whose pediatrician does not have privileges at this facility
  • In some hospitals, the pediatric hospitalist staff attend newborns following delivery
  • Provide consultation services requested by physicians in other services

In addition, pediatric hospitalists may provide attending physician management services for private patients whose physicians elect to use a hospitalist service for inpatient management. Many contracts require at least one physician to remain in the hospital at all times. In low-volume programs, after-hours and weekend coverage may be provided on an on-call basis, generally with daily rounds. Many services require attendance at high-risk births, as requested, as well as first-responder service to the neonatal intensive care unit when a neonatologist is not in-house.

Volume-related benchmarks include total net annual payments excluding medical direction in ratio to average daily census of the whole hospital.

Key Factors to Consider in Contract Analysis:

  • Is coverage on site 24 hours per day? Are weekends included?
  • How many physicians are required to manage the case load?
  • What is the average daily census attended by the hospitalist service?
  • What are the professional fee collections per physician? How do collections compare to industry benchmarks?
  • What is the frequency of call or coverage for the participating panel?
  • Is the in-house coverage requirement less than 6 hours per day or less than 42 hours per week?
  • Is the proportion of Medicaid or public patients extremely high or low?


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