Readmission programs could violate anti-fraud laws

Although Medicare penalties for high rates of readmissions offer an opportunity for hospitals to improve quality and lower cost, efforts to reduce readmissions could violate fraud and abuse laws, Report on Medicare Compliance reported.

Lawyers warn that discharge planning and transitional care programs could cross the line from care improvements to potentially fraudulent practices if hospitals can't prove that such services are part of inpatient care.

"When you reach out to the community, you start providing additional services and run the risk of beneficiary inducements and arrangements with other providers and get into more hardcore compliance risks like anti-kickback and Stark," attorney Tim Blanchard of Blanchard Manning in Orcas, Wash., told Report on Medicare Compliance.

For example, the situation gets muddled with patient outreach. Calling patients a few hours after discharge could be in compliance, whereas delivering a prescription to a patient's home or providing transportation to a doctor's appointment could be considered a beneficiary inducement, the article noted.

But services that are part of the discharge plan, such as vaccine reminders, already are paid by the DRG so there's no inducement. "But if it's brand new, not something they are just doing better," the hospital may face scrutiny under the civil monetary penalty law, Blanchard noted.

Congress-mandated patient choice also creates potential problems for hospitals trying to keep patients from bouncing back to their facilities, according to Report on Medicare Compliance. Hospitals must give patients a list of available post-discharge providers, but setting up post-discharge appointments for patients could violate the patient choice requirement.

That condition of participation pits hospitals' efforts to give patients a choice against their desires to influence the quality of post-discharge care, according to an article in the Payment Matters Newsletter from law firm Ober Kaler.

For more:
- read the Report on Medicare Compliance story on AIS Health
- here's the Payment Matters article