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Our Commitment to Compliance

By Tim O’Toole, Chief Executive Officer

In September 1995, years before the OIG published compliance guidelines for hospices, VITAS adopted a compliance policy and code of conduct.  Today this policy affirms “VITAS employees and agents must know that hospice services will only be reimbursed if ordered, certified, covered, provided and are reasonable and necessary for the patient, given his or her clinical condition.  VITAS will only seek reimbursement for services it has reason to believe are reasonable and necessary for the palliative care and management of the terminal illness and were ordered by a physician or other appropriately licensed individual.”  

To this day, there remains no clearer statement articulating our collective commitment to both our patients’ best interests and our regulatory obligations.  I say this because, as those who work at VITAS already know, the foundation behind our long standing practice of not only meeting, but oftentimes exceeding, regulatory compliance thresholds, is not limited to policy and procedure written on a piece of paper.  It is intensely personal and the essence of every VITAS employee.  

Professional Integrity

Every VITAS employee makes this statement during their orientation: “I have received a copy of the VITAS Healthcare Corporation Employee Handbook, which includes the Prohibition Against Harassment, Equal Employment Opportunity, VITAS Compliance Policy and Code of Ethical and Legal Conduct.  I have read the handbook, understand it and agree to follow it during my employment with the Company.”

This kind of personal responsibility is at the core of VITAS’ commitment to compliance.  It is not just that the company sets out a compliance policy, or that the principles behind that policy have been translated into a code of conduct.  It’s not just that as healthcare practitioners most of our employees are obligated by professional statutes and regulations to behave in a manner consistent with honesty, integrity, and best practice.  It’s not just that procedural checks and balances have been built into VITAS practices to build a culture of compliance within the organization.

In the end, it comes down to this.  Every VITAS employee takes personal responsibility for ethical and legal conduct.  Through a simple act of attestation – signing one’s name – every VITAS employee willingly obligates themselves to the highest standards with respect to their conduct every day of their employment.

This is no surprise, really, when you think about it.  The kind of professionals drawn to work with the dying would naturally have as a part of their core values a commitment to doing the right thing.  There is something about spending time with those nearing life’s end that magnifies one’s devotion to living life in accordance with principles larger than one’s own self interest.  Watching how people die, one can’t help but reflect on what life means and what we would want our legacy to be.

And so it’s no surprise that VITAS’ compliance program would start here.  It’s the people working at VITAS that make our compliance program what it is.  It is the dedication of each employee to a code of conduct, to professional standards, to best practices and taking personal responsibility that makes our compliance program not just a set of words, procedures, checks and balances.  It is not an exaggeration to say that compliance is literally a living, breathing thing at VITAS, because at VITAS compliance starts with our people.

It doesn’t end there, of course.  Compliance is not only the embodiment of the best professional conduct of our employees.  It’s also a duty.  So VITAS has built a robust compliance program on this solid foundation that helps to channel these good intentions into organizational practices that assure a commitment to integrity is maintained at all levels of our company.  What follows is a description of these compliance practices. 

Compliance Guidance for Hospices

In 1999 the Office of Inspector General published guidelines for hospices that identified the unique risk areas inherent in hospice care.  When these compliance risk areas were published, those of us associated with VITAS recognized these were areas that already had been addressed in VITAS policy and educational materials, and they remain the focus of compliance training for VITAS employees to this day.  These risk areas include the following:

  • Eligibility
  • Billing Practices
  • Hospice Services in Nursing Facilities
  • Clinical Risks
  • Marketing Practices

 It is appropriate that training about the unique ways these risks might surface in hospice is at the core of compliance at VITAS because, in order to maintain a culture of compliance, all VITAS employees need to understand these issues.  Compliance training is completed by each employee during orientation and through the VITAS Annual Update.  This ensures that VITAS employees are attuned to the kinds of behavior that could result in compliance challenges and know how to address these issues should they be observed.  Training is at the core of the VITAS compliance program, but training is only one aspect of an effective compliance program.  

The OIG recommends that for a hospice compliance program to be comprehensive it should include:

  • Implementing written policies, procedures, and standards of conduct
  • Designating a compliance officer and compliance committee
  • Conducting effective training and education
  • Developing effective lines of communication (i.e., hotline or other reporting system)
  • Enforcing standards through well-publicized disciplinary guidelines
  • Conducting internal monitoring and auditing
  • Responding promptly to detected offenses and developing corrective action

We have already been exposed to some of VITAS’ written policies and procedures above, and the VITAS code of ethical and legal conduct.  VITAS maintains policies related to billing and coding standards and “false claims” prevention.  Of equal importance are the ways in which these policies have been built into the VITAS Exchange, VITAS’ patient management system.  VITAS developed these systems with checks and balances and continues to invest in staying current on billing rules to prevent claims from being submitted until all necessary documentation is in the patient record.

As mentioned above, many hours each year are invested in updating the compliance education and training materials – VITAS’ Annual Update – with the latest information presented in a memorable way.  These materials present practical advice regarding how to handle various situations that might have a compliance aspect, and suggest methods of discussing or reporting compliance concerns.  A link to the 2013 Annual update can be found at the end of this document.

VITAS’ Compliance Officer, currently Senior Vice President Bob Miller, chairs VITAS’ Compliance Committee and monitors VITAS’ Compliance Hotline.  Posters placed in prominent locations around VITAS offices and inpatient units serve as effective reminders to employees about how to reach the compliance hotline, and stress that anonymity can be maintained when that is desired by an employee reporting a potential compliance issue.

Compliance auditing and monitoring is done at a variety of levels at VITAS, starting with the program, and the Compliance Committee regularly reviews reports collated at the corporate level to monitor trends.  These reports include updates on any current corrective action plans and any compliance related disciplinary action.  In this way, all seven elements the OIG has identified for a comprehensive compliance program are present in VITAS’ compliance efforts. 

Integration of a Compliance Culture into Daily Operations

As a hospice leader, VITAS takes its responsibility to create a culture of compliance very seriously.  As a result, VITAS has developed integrated tools and processes to meet and exceed compliance requirements that are so much a part of daily operations that they might not at first be thought of as compliance tools.  Here is a sample of these activities:  

Patient Eligibility Review

Patient eligibility review belongs at the team level.  In addition to consulting with the attending physician as a part of the initial admission certification, admission initial certifications and recertifications are conducted by VITAS physicians, many of whom hold specialty certifications in hospice and palliative care.  Narrative descriptions of the patient are carefully prepared as part of this process so that anyone reviewing the patient record subsequently has a record of the physician’s thought process at each point along the patient’s stay where eligibility was reviewed.

Many encounters in which patient information is relayed amongst team members for care planning purposes also include a compliance element.  Team physicians are consulted whenever a change of symptoms might require a change in treatment orders.  These same physicians might order a change in level of care as a result of this encounter.  Physician oversight of the treatment plan assures that the plan of care meets the needs of that patient and family, but it is also done to assure that the appropriate level of care intensity is being provided to the patient.  

Although doctors these days rarely make house calls, VITAS doctors do.  Physicians oversee the care of every patient on service through telephonic consultation and in person visits.  During these visits, physicians may be performing any number of tasks, including patient assessment, evaluating responses to treatments, providing education and consultation to patients and their families, ordering new treatments to manage patient symptoms causing distress, evaluating clinical appropriateness, and conducting required face-to-face encounters for patients on service greater than six months.  The integrity of the doctor patient relationship is of the utmost importance at VITAS.  No panel of corporate overseers second guess the judgment of the physician at the patient’s bedside.

Corporate level activities in this area include the confirmation of accurate patient data entry, as well as a review of benefit eligibility through the CMS Common Working File. 

Integrated Management of Billing Data

As a result of VITAS’ ongoing investment in systems, compliance-related patient eligibility determinations are tied together in VITAS’ proprietary patient management software.  In other words, before any bill is submitted for payment, our systems make sure that bill is tied to a properly eligible claim.

Benefit information, certification and recertification compliance checks, and the automated uploading of associated physician dictation are just a few of the items carefully monitored through the VITAS Exchange so that no bill is ever dropped until these items have been confirmed.  Physician visit notes and narratives are dictated, and electronic signatures are obtained.  This assures authenticity and legibility of these critical documents and enables seamless integration into the management of the billing data flow.

Logic built into the system prevents billing if a certification is not obtained in a timely way, for instance, or if a physician face-to-face encounter is late.  Any exceptions are reviewed and evaluated in an effort to prevent recurrence.  

In an effort to assure that each program has a dedicated subject matter expert to review and evaluate elections, certifications, recertifications, physician narratives, and associated physician dictation, VITAS invests nearly two million dollars a year to maintain local Financial Record Specialist personnel whose job is singularly focused on billing compliance management.  The Financial Records Specialist is responsible to ensure all billing documents are complete and accurate, and then enters the associated data into the VITAS Exchange.  Once these tasks are done, a scan of the complete documentation is uploaded into VITAS’ internal intranet storage portal called the Patient Document Viewer.  Finally, a VITAS manager conducts a “quality assurance” review to ensure that the documents are complete and data are entered correctly before releasing the record for billing.

Compliance with standards is monitored by internal compliance advocates who review a representative sample of billing documents each month.  Feedback on any identified issues is given to the responsible individual in the program, and trends are monitored on a monthly basis to assure that any issues requiring attention are promptly addressed.  In addition to these reviews, VITAS’ parent company, Chemed, maintains an Internal Audit function to independently review these documents as well.  Regular reports from these reviews are provided to the VITAS Compliance Committee and the Chemed Board of Directors for yet another level of oversight.

Compliance Training and Coaching

In addition to the VITAS Annual Update compliance training for every employee, ongoing regulatory coaching on compliance issues is provided to employees with compliance related responsibilities.  This coaching is provided by dedicated corporate compliance staff.  These regular conversations with compliance personnel not only keep us up to date on hospice regulations but they also reinforce VITAS’ culture of compliance.  Compliance outreach through these calls typically include Vice Presidents of Operations, General Managers, Patient Care Administrators, Regulatory Compliance Group personnel, Financial Records Specialists and Medical Directors.  In addition, regulatory updates also are provided by dedicated VITAS Fiscal Intermediary Review staff.

From the very first day that a new manager joins VITAS, special effort is taken to assure that the new manager is prepared to take on the compliance aspects of their roles in accordance with new manager training which is conducted quarterly.  Beyond this intensive training, compliance is further enhanced by participation in hospice regulatory mailings, Fiscal Intermediary Contractor conferences and workshops, as well as membership to various compliance workgroups all geared to make VITAS managers and personnel among the most informed compliance practitioners in the hospice community.  

Reporting of Compliance Concerns

As you know, VITAS is a large organization and we are growing.  Our hospice programs are spread across 18 states and the District of Columbia, and we continue to expand each year into new areas where our care can make a difference.  To ensure our strong culture of compliance throughout the organization, VITAS maintains not just the VITAS Compliance Hotline at 1-800-63-VITAS (638-4827) as mentioned above, but a robust network of compliance hotlines as described in this section.  The compliance hotlines assure that employees have ready access to a way of reporting any compliance issues that need attention.  Also, for any employee who feels at all uncomfortable discussing issues in the program or with their immediate supervisor, these hotlines provide the ability to report situations anonymously.  Any compliance allegations reported are investigated under the supervision of the Compliance Officer and involve the Chief Operating Officer, Vice President of Operations for the affected program, the National Medical Director and legal counsel when appropriate.   

The HIPAA Hotline exists to field calls concerning potential HIPAA violations.  When a HIPAA issue is identified, such as lost or stolen paper documentation, patients and families are notified of the issue.  Following Federal law, the VITAS HIPAA privacy officer annually makes required filings about any HIPAA issues to the Secretary of HHS.  

Additionally, VITAS’ parent company maintains the Chemed Theft and Fraud Hotline to give those with concerns yet another avenue to report potential concerns.  The message to VITAS employees is clear: VITAS wants to know of any concerns employees might have so that they can be thoroughly investigated.

Compliance is Everyone’s Job

And so we have come full circle, back to highlighting the individual responsibility shared by each VITAS employee to assure that compliance is just as top a priority as is excellent patient care.  Policy 1:04 was quoted at the beginning of this discussion about individual responsibility.  That policy goes on to say:  “Failure to comply with the VITAS Compliance Policy and Code of Ethical and Legal Conduct, as well as other elements of VITAS’ compliance program is a form of employee misconduct.”

When an employee has concerns the employee must take personal responsibility.  As I noted at the beginning of this paper, through a simple act of attestation – signing one’s name – every VITAS employee willingly obligates themselves to the highest standards with respect to their conduct every day of their employment.  The organization supports employees in this endeavor through its systems, structures and processes.  All of this is to say that at VITAS, compliance is not a sidelight, something we attend to when everything else is done.  At VITAS, no matter who you are or what you do, compliance is everyone’s job – every day.

VITAS Compliance Hotline:  1-800-63-VITAS (638-4827)