Case Study- Compliance Matters

Selena is the Director of Health Information for the Home Health division of Anywhere General Healthcare Systems (AGHS). AGHS is an effective health care system that includes a 1,500-bed acute care hospital, home health, a 30-bed skilled nursing unit, a 50-bed rehabilitation unit, and a health insurance provider. There are several other smaller hospitals in the same city as AGHS, but none of these hospitals provide comprehensive services as AGHS does.

Selena has been in her position for about one year. Her department consists of four coders, two filing clerks, a receptionist, a Release of Information Specialist, and a scheduler. Selena reports directly to the Home Health Administrator, who reports to the Chief Executive Officer of AGHS. Selena came to AGHS with 15 years of experience in various health information management settings. In addition to her Registered Health Information Administrator credential, she is a Certified Compliance Professional. Immediately before coming to AGHS, Selena worked as a compliance consultant for a nationwide health care consulting firm. Selena is recognized nationwide among her peers and highly respected in the health care community. She has published numerous peer-reviewed articles in professional journals and co-authored a compliance textbook. During her interview with AGHS, the administrator informed Selena that the organization could benefit from her compliance training because they did not yet have a formal compliance program. Her predecessor had a general business degree and had no previous experience in the health care environment. He had been unaware of home health-specific regulations, Health Insurance Portability and Accountability Act (HIPAA), Joint Commission, or Centers for Medicare and Medicaid Services (CMS) guidelines. His job was to manage the office staff and ensure they were doing their jobs. AGHS had decided that it was necessary to hire a credentialed health care professional with knowledge of compliance and other regulatory guidelines because they were aware some areas in home health were non-compliant.

When Selena started at AGHS, she assessed each department area to determine improvement opportunities. The receptionist and scheduling staff seemed to be doing well in terms of compliance. Clinical staff members had informed them, and some had researched home health compliance issues because they knew this was an issue based on what the clinical staff had shared.

When Selena assessed the Release of Information Specialist's work, she was shocked to discover that the individual in this position had no formal training. She had previously been a receptionist and was promoted when the release of information position was vacated. There was no written job description and no guidelines previously provided to the Release of Information Specialist addressing the various types of information requests that may be presented. The Release of Information Specialist had never been informed about state laws, national laws, or HIPAA. The Release of Information Specialist told Selena that her job was simple. When she received a request for records, she copied them and sent them out. She would pass that on to the director if she received a subpoena, and she had no clue how the records were processed for subpoenas. Selena provided the Release of Information Specialist with appropriate education regarding HIPAA, state laws, and other appropriate issues. A written job description was created, and the Release of Information Specialist demonstrated understanding and agreed to ask Selena if there was ever any question regarding record release.

The filing area was organized, but there was no formal system for chart check-out. Selena initiated a manual sign-out system, which seemed to work well after a couple of weeks. Upon more in-depth assessment of the filing area, Selena discovered unsigned plan of care forms for patients who had most likely been billed. She even found some of these forms over a year old and not yet signed. The file room staff members were unaware of the CMS requirements for the physician's plan of care to be signed before billing. Selena initiated a process to ensure the timeliness of the physician's signature for the plan of care forms and communication to the billing office.

The four coders in Selena's department had all been with AGHS for a reasonably long time, ranging from 6-25 years in longevity with the organization. She met with each coder individually before meeting with the group. During this assessment, Selena learned that none of the coders had ever gone through any formal coding education. She had concerns about this; there were no credentialed coders on staff, and they had all been trained internally. When Selena met with the coders as a group, she informed them that she would be doing an internal audit on their coding. The coders reacted defensively, so Selena explained that the audit was simply a component of the compliance plan that she was working on implementing. This satisfied their concerns, and they were cooperative.

The first month of coding audits demonstrated a 16% accuracy rate for the coders. Selena developed an all-day training session that she required the coders to attend. She reviewed coding conventions and home health billing guidelines. She informed the coders that the audits would continue, and she would watch for trends in the type of errors found and provide monthly education to get the coders compliant. The coders' accuracy improved over time, and eventually, they were at 95% accuracy by the end of the year.

The Home Health Administrator was highly impressed with Selena's accomplishments and the changes she had implemented in her first year with the organization. She had thoroughly educated her staff regarding areas of compliance that were previously foreign to them. She developed a comprehensive policy and procedure manual for her department that included specific job descriptions for each position. Selena also compiled a significant start on a compliance manual for the home health division of AGHS from scratch. When setting goals for the following year during her annual evaluation, one of Selena's goals was to generate effective communication between her department and the billing department, which was located in another building. Selena indicated to the administrator that this might help eliminate additional noncompliance issues. Before this time, Selena's staff did not realize the relationship between their functions and the functions of the billing department. The administrator agreed that developing communication between the two departments would further reduce compliance issues and encouraged Selena to perform an internal billing audit because the results were so dramatic after initiating the coding audits.

Selena contacted Janet, the Director of Billing, to discuss her plans. Janet was highly cooperative and agreed that the audits would be a positive step toward becoming compliant. Janet was aware of some billing issues that she had previously pointed out to the administrator and hoped that Selena's audit would help support her concerns. It did not take Selena long to discover the issue that Janet had previously addressed.

AGHS Home Health serves a diverse population. This population includes Medicare, Medicaid, self-pay, commercial insurance, elderly, middle-aged, postpartum, and newborn patients. Selena observed her billing audit that no visits to the postpartum and regular newborn patients were billed. She discussed this finding with Janet, who informed Selena that she had brought this to the administrator's attention when she started at the organization two years prior. Janet was told that the organization provides complimentary home health visits one week postdischarge for the mothers and babies. Janet told Selena that she did not think much more of the issue because the administrator presented it to her confidently that it was an acceptable practice. Selena pointed out that because the organization serves Medicare patients, they could not provide a service to anybody else for a lesser charge, and these complimentary visits were less than anything being charged to the Medicare patients.

Selena took her concerns regarding the complimentary visits to the administrator. She was told that the complimentary visits were made for public relations and that they served as a successful marketing tool to bring more business into the organization. Selena refuted this statement by providing information to the administrator about the legal implications of giving complimentary visits to non-Medicare patients. The administrator stated they would lose too much business if they were to discontinue the complimentary visits and that the issue was nonnegotiable and would not be open for discussion again.

Selena found herself in a situation of non-compliance with nowhere to turn. The organization did not have any form of compliance plan before her employment. The administrator had not yet created a position for a compliance officer, and there was no means for employees to submit compliance issues. This was the best job Selena had ever had. She would not be able to make nearly as much working in a staff position at any of the other smaller area health care organizations, and she was unaware of any openings at the other facilities. She was not comfortable working for an organization that knowingly acted in a non-compliant manner, and she did not want to risk her future by continuing to be in a position that supported the practice. Suppose the Office of the Inspector General sanctioned the organization for this situation while she continued to work there, aware of the issue. In that case, she could lose her compliance credential. She could face the possibility of never being able to work for an organization that bills Medicare or Medicaid patients ever again. However, she did not have any other job options at the time.

Discussion Questions

1. What internal and external forces impact Selena's concerns in this case?
2. What ethical concerns are presented in this case?
3. What legal issues need to be considered regarding this case?
4. Summarize the information Selena should include in formal training for newly hired staff in the department about both legal and ethical issues that should be addressed.
5. If you were Selena, how would you handle this situation?
6. What could the administrator do differently in this case?
7. Using the case method, evaluate possible actions that Selena should take and determine the best