Compliance

At LHC Group, we are firmly committed to the highest standards of ethics, integrity, professionalism, and compliance. We’re proud to say our comprehensive compliance and ethics program has been recognized as a model for home healthcare nationwide.

Our compliance and ethics program includes auditing and monitoring, enhanced lines of communication between the chief compliance officer and employees, consistency in the standards we set for ethics, and compliance and increased awareness of these standards through a robust training and education program.

In everything we do, our actions and decisions are aligned with our purpose, mission and vision. We are committed to doing the right thing every time — without exception.

Our compliance and ethics program was developed to help ensure we conduct our business in compliance with all applicable federal and state laws, rules and regulations and to reduce the risk of misconduct. According to the Office of the Inspector General, a well-built compliance program should have a strong foundation that includes the following seven elements:

• Written policies, procedures and standards of conduct
• Designated compliance officer and compliance committee
• Effective training and education
• Reporting and investigating: effective lines of communication;
• Enforcement and discipline: well-publicized disciplinary guidelines
• Strong internal monitoring and auditing program
• Response and prevention: prompt response to detected offenses

To follow the OIG guidelines, we have developed a compliance and ethics program that consists of the following elements:

• Development, distribution and routine review and update of the Code of Conduct and Ethics, as well as policies and procedures that promote LHC Group’s commitment to compliance and ethic and address specific areas of risk to the organization
• Designation of a chief compliance officer, who is responsible for overseeing and monitoring the compliance and ethics program, and a compliance committee that advises the chief compliance officer and assists in the execution of the compliance and ethics program
• Regular and effective training and education, which addresses the various components of the compliance and ethics program and effectively communicates LHC Group’s standards and procedures
• Development of an anonymous third-party compliance hotline and website, the IntegrityLine, for employees to communicate with the chief compliance officer to report potential violations or ask questions
• A system to respond to allegations of improper activities and to consistently enforce appropriate disciplinary action for non-compliance
• Performance of regular compliance audits and evaluation techniques, internally and externally, to monitor compliance with relevant healthcare standards and regulations
• Immediate response to and the investigation of possible violations of the Code of Conduct and Ethics, compliance policies and procedures and applicable laws, rules or regulations, as well as appropriate corrective action initiatives and consistent discipline for any violations that have occurred

In addition, we have also established extensive policies and guidelines anchored around privacy and security and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Health Information Technology for Economic and Clinical Halt Act (the HITECH Act), and HIPAA regulations for our patients, employees and business associates.

Our code of conduct and ethics provides guidance to all LHC Group employees, contractors and board members on carrying out daily activities within appropriate ethical and legal standards. The code of conduct and ethics was developed to help ensure we meet our ethical standards and comply with applicable laws, rules and regulations. It is a critical component of our overall compliance and ethics program and is an important resource — especially in situations where questions may arise about determining the right thing to do.

The code of conduct and ethics includes the potential consequences to both LHC Group and our employees for failure to comply with all statutes, regulations and guidelines applicable to federal and state healthcare programs. The standards set forth in the code are mandatory and should be applied both in letter and in spirit. The business practices that are addressed in the code include, but are not limited to:

• awareness of fraud and abuse
• legal and regulatory compliance
• quality of care
• coding and billing
• conflicts of interest
• patient information and privacy
• confidential information
• workplace conduct and employment practices

All employees and representatives of LHC Group are required to conduct themselves in a way that supports the highest standards of ethics and integrity and to follow the standards set forth in our code of conduct and ethics and our policies and procedures without exception.

Download the UHG code of conduct.

All new employees and new contractors — and all employees and contractors on an annual basis —must attend a one-hour orientation on the LHC Group corporate compliance and ethics program. We also require annual distribution of the code of conduct and ethics; each employee, including contractors, must receive, acknowledge, review and attest to the code. All attestation statements are tracked and stored.

Additional specialized training is offered in areas such as eligibility for home health and hospice, HIPAA, privacy and security, clinical and quality, coding, billing and reimbursement and sales and marketing. Training is delivered through webcasts, online courses and instructor-led sessions. All training is tracked in the company’s learning management system.

We have a full suite of compliance policies and procedures. We perform a routine review and revision of our policies and procedures to stay abreast of both internal and external developments. All employees receive updated policies and procedures for review, specifically those that are directly related to job function.

Our compliance policies include a code of conduct related to sales, marketing, education and entertainment activities with referral sources. This policy establishes rules and procedures governing our employees’ interactions with current and potential referral sources as well as those with the ability to influence or recommend a referral to one of our providers, helping ensure current regulations and laws are followed.

LHC Group has developed extensive auditing and monitoring programs to assess internal controls and processes for compliance with all applicable laws, rules and regulations. The Office of the Inspector General has published areas of concern for home health agencies, hospice and acute care facilities. Our compliance department has developed individual work plans and audit tools for each area of concern to assist in evaluating our company’s risk for each of these areas. Compliance professionals work in conjunction with other departments to accomplish the necessary goals and objectives for each compliance work plan.

An example of certain audits that are conducted on- and off-site include:

• OIG and risk-based work plan audits that encompass guidelines surrounding Stark and anti-kickback regulations, service utilization, Part B payments, HIPAA compliance, accuracy of billing and coding, discharge and admission procedures and other important risk areas
• Clinical and billing compliance audits of medical records performed by clinicians and certified home health coders
• Monthly customized compliance risk indicator reports for every home health agency to track and monitor key risk indicators such as therapy utilization, outliers and length of stay
• Monthly audit of sales and marketing expenses and compliance with our code of conduct for sales and marketing
• Routine audits of our joint ventures
• Monthly audits of our medical director program, including a review of all medical director timesheets

Audit frequencies range from monthly to annually depending on potential risk and vulnerability factors. Findings and recommendations are documented and monitored through our compliance information system. Each review provides valuable guidance to assist in strengthening controls and improving overall performance throughout our agencies and facilities. The analysis of this data assists in identifying both trends and opportunities for improvement within our company.

Our compliance department also conducts an annual risk assessment. This annual risk assessment process includes:

• A review of the OIG work plan and other regulatory and industry guidance for risk areas applicable to each industry in which we operate
• Surveys and/or interviews with personnel, including field clinicians, agency/facility leadership, home office staff and senior management
• Analysis of qualitative and quantitative information to determine appropriate risk areas and future audit activity for the approaching year’s audit work plan

LHC Group is committed to maintaining the confidentiality, privacy and security of its patients’ protected health information. Consistent with the Health Insurance Portability and Accountability Act, we do not use, disclose or discuss patient-specific information, including patient financial information, with others unless it is necessary to serve the patient or required by law. A copy of our Notice of Privacy Practices is provided to each patient at the time of admission. The notice describes how protected health information may be used and disclosed and how to access PHI.

We are committed to being conscientious and accountable when handling confidential company information. In addition, because of its confidential nature, business, health and financial information must be protected by an effective internal control environment, including policies and procedures to secure the company’s assets, and made available outside the company only with appropriate authorization and after consideration of the interests of LHC Group as a whole.

Protecting LHC Group’s information assets is everyone’s responsibility. Examples of confidential information include:

• Health information of those we serve
• Company financial information, including financial statements, payroll records, accounts payable summaries, vendor listings and price/cost information
• Written and verbal agreements between LHC Group and employees, agents, strategic partners, vendors and/or other third parties
• Trade secrets
• Due diligence information about potential acquisitions
• Customer lists and agreements, market share data and strategic plans
• Policies, procedures and processes

UHG Compliance & Ethics HelpCenter provides a confidential and anonymous line of communication for employees, contractors and third parties to communicate with the LHC Group compliance department. Individuals may contact the UHG Compliance & Ethics HelpCenter 24 hours a day, seven days a week, at 1.800.455.4521 or at www.uhghelpcenter.ethicspoint.com. The toll-free telephone number and website are hosted by an independent third-party vendor.

LHC Group makes every effort to maintain, within the limits of the law and within the bounds of an appropriate investigation, the confidentiality of the identity of any individual who uses the UHG Compliance & Ethics HelpCenter. There will be no retribution or discipline for anyone who reports a possible violation in good faith.

The success of our corporate compliance and ethics program relies on high-level oversight from the UHG Board of Directors and Senior Management, as well as buy-in, support and accountability from employees. Listed below are the committees and individuals who support our compliance and ethics program.

• The UHG Executive Compliance Committee provides regular guidance regarding the direction of the company’s compliance and ethics program. In addition, the committee receives regular reports on the status of the compliance and ethics program.
• The compliance committee monitors the compliance and ethics program and is comprised of members of senior management and other key leaders within the LHC Group family. The compliance committee receives reports on the various audits and investigations performed by the compliance department.
• Our chief compliance officer oversees the compliance and ethics program and evaluates compliance issues/concerns within the organization. The chief compliance officer helps ensure that the board of directors, management and employees are in compliance with the rules and regulations of regulatory agencies, that company policies and procedures are being followed and that behavior in the organization meets the company’s code of conduct and ethics.
• Each employee has a shared responsibility and commitment to our mission of healthcare service to our patients. Compliance and ethics are the responsibility of every LHC Group employee, and every employee is required to always do the right thing, without exception, and to make all clinical decisions based solely on the needs of the patient.

As a national leader in post-acute care, LHC Group is pleased to share compliance resources with others in the healthcare industry. The following information may be helpful to healthcare organizations focused on compliance issues.

Industry links

Office of Inspector General, US Department of Health and Human Services

http://oig.hhs.gov

Centers for Medicare & Medicaid Services

http://www.cms.gov

Health Care Compliance Association

http://www.hcca-info.org

National Association for Home Care and Hospice

http://www.nahc.com

American Association for Homecare

http://www.aahomecare.org

American Academy of Hospice and Palliative Medicine

http://www.aahpm.org

Beacon Health

http://www.beaconhealth.org

National Hospice and Palliative Care Organization

http://www.nhpco.org