Federal Register / Vol. 63, No. 79 / Friday, April 24, 1998 / Notices 20415

This notice announces a forthcoming

meeting of a public advisory committee

of the Food and Drug Administration

(FDA). The meeting will be open to the

public.

Name of Committee: Science Board to

the Food and Drug Administration.

General Function of the Committee:

To provide advice and

recommendations to the agency on FDA

regulatory issues.

Date and Time: The meeting will be

held on May 19, 1998, 9 a.m. to 3:30

p.m.

Location: Doubletree Hotel, Plaza

Room, 1750 Rockville Pike, Rockville,

MD.

Contact Person: Susan K. Meadows,

Office of Science (HF–32), Food and

Drug Administration, 5600 Fishers

Lane, Rockville, MD 20857, 301–827–

4591, or FDA Advisory Committee

Information Line, 1–800–741–8138

(301–443–0572 in the Washington, DC

area), code 12603. Please call the

Information Line for up-to-date

information on this meeting.

Agenda: Information will be

presented to the board regarding: (1)

FDA’s research and science programs,

(2) the process for peer review and

findings from the Subcommittee for the

Center for Biologics Evaluation and

Research Review, (3) the status of the

Biomaterials Forum project (a process

for information exchange addressing

issues in biomaterials science), (4) the

activities of the Science Board

Subcommittee on Toxicology, and (5) a

proposed model for support for FDA

Science.

Procedure: Interested persons may

present data, information, or views,

orally or in writing, on issues pending

before the committee. Written

submissions may be made to the contact

person by May 1, 1998. Oral

presentations from the public will be

scheduled between approximately 2

p.m. and 3 p.m. Time allotted for each

presentation may be limited. Those

desiring to make formal oral

presentations should notify the contact

person before May 1, 1998, and submit

a brief statement of the general nature of

the evidence or arguments they wish to

present, the names and addresses of

proposed participants, and an

indication of the approximate time

requested to make their presentation.

Notice of this meeting is given under

the Federal Advisory Committee Act (5

U.S.C. app. 2).

Dated: April 17, 1998.

Michael A. Friedman,

Deputy Commissioner for Operations.

[FR Doc. 98–10970 Filed 4–23–98; 8:45 am]

BILLING CODE 4160–01–F

DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Office of Inspector General

Publication of OIG Special Fraud Alert:

Fraud and Abuse in Nursing Home

Arrangements With Hospices

AGENCY: Office of Inspector General

(OIG), HHS.

ACTION: Notice.

SUMMARY: This Federal Register notice

sets forth a recently issued OIG Special

Fraud Alert concerning fraud and abuse

practices involving nursing home

arrangements with hospices. For the

most part, OIG Special Fraud Alerts

address national trends in health care

fraud, including potential violations of

the Medicare anti-kickback statute. This

Special Fraud Alert, issued to the health

care provider community and now

being reprinted in this issue of the

Federal Register, specifically identifies

and highlights some vulnerabilities in

nursing home arrangements with

hospices and instances of potential

kickbacks between nursing homes and

hospices to influence the referral of

patients.

FOR FURTHER INFORMATION CONTACT: Joel

J. Schaer, Office of Counsel to the

Inspector General, (202) 610–0089.

SUPPLEMENTARY INFORMATION:

I. Background

The Office of Inspector General (OIG)

issues Special Fraud Alerts based on

information it obtains concerning

particular fraudulent and abusive

practices within the health care

industry. These Special Fraud Alerts

provide the OIG with a means of

notifying the industry that we have

become aware of certain abusive

practices which we plan to pursue and

prosecute, or bring civil and

administrative action, as appropriate.

The Special Fraud Alerts also serve as

an effective tool to encourage industry

compliance by giving providers an

opportunity to examine their own

practices.

Special Fraud Alerts are intended for

extensive distribution to the health care

provider community, as well as those

charged with administering the

Medicare and Medicaid programs. To

date, the OIG has published in the

Federal Register the texts of 8

previously-issued Special Fraud Alerts

(December 19, 1994, 59 FR 65372;

August 10, 1995, 60 FR 40847; and June

17, 1996, 61 FR 30623), and we have

indicated our intention of publishing

future Special Fraud Alerts in this same

manner as a regular part of our

dissemination of such information.

With regard to nursing home

arrangements with hospices, this newlyissued Special Fraud Alert discusses (1)

the nature of hospice care and who is

eligible to receive such care; (2) the

reimbursement for hospice care

provided by nursing homes; (3) the

vulnerabilities in nursing home

arrangements with hospices; (4) several

suspected kickback arrangements that

are designed to induce Medicare or

Medicaid referrals. A reprint of this

Special Fraud Alert follows.

II. Special Fraud Alert: Fraud and

Abuse in Nursing Home Arrangements

With Hospices (April 1998)

Office of Inspector General was

established at the Department of Health

and Human Services by Congress in

1976 to identify and eliminate fraud,

abuse and waste in the Department’s

programs and to promote efficiency and

economy in departmental operations.

The OIG carries out this mission

through a nationwide program of audits,

investigations, and inspections.

To reduce fraud and abuse in the

Federal health care programs, including

Medicare and Medicaid, the OIG

actively investigates fraudulent schemes

to obtain money from these programs

and, when appropriate, issues Special

Fraud Alerts that identify segments of

the health care industry that are

particularly vulnerable to abuse. This

Special Fraud Alert focuses on the

interrelationship between the hospice

and nursing home industries and

describes some potentially illegal

practices the OIG has identified in

arrangements between these providers.

What Is Hospice Care and Who Is

Eligible To Receive It?

Medicare’s hospice benefit provides

palliative care to individuals who are

terminally ill. Palliative care focuses on

pain control, symptom management,

and counseling for both the patient and

family. Medicare hospice payments

increased from about $958 million for

Fiscal Year 1993 to over $1.8 billion for

Fiscal Year 1995. Although the hospice

benefit is still a relatively small portion

of total Medicare Part A expenditures

(about 1.5 percent), it has grown

considerably over the past several years.

In order to elect the hospice benefit,

a Medicare beneficiary must be entitled

to Medicare Part A services and certified

as terminally ill, which is defined as a

medical prognosis of a life expectancy

of 6 months or less if the illness runs its

normal course. A beneficiary who elects

to enroll in a hospice program waives

his or her rights to all curative care
20416 Federal Register / Vol. 63, No. 79 / Friday, April 24, 1998 / Notices

related to his or her terminal illness.

Medicare will continue to pay for

services furnished by the patient’s nonhospice attending physician and for the

treatment of conditions unrelated to the

terminal illness.

The hospice must have a written plan

of care which covers physician and

nursing services; physical, occupational,

and speech therapy; medical social

services; home health aides and

homemakers; short-term inpatient care;

counseling; respite care; and medical

supplies, including drugs and

biologicals. Certain of the hospice

services (‘‘core services’’) must be

provided directly to the beneficiary by

employees of the hospice, while other

non-core hospice services may be

provided in accordance with contracts

with other providers. However, the

hospice must retain professional

management for all contracted services.

Reimbursement for Hospice Care

Provided in Nursing Homes

Medicare does not have a separate

payment rate for routine hospice

services provided in a nursing home.

Because hospice services are typically

provided to patients in their homes, the

routine home care hospice rate does not

include any payment for room or board.

For services provided to patients in

nursing homes, hospices receive the

Medicare routine home care rate, which

is a fixed amount per day for the

services provided by the hospice,

regardless of the volume or intensity of

the services provided. Accordingly,

where the hospice patient resides in a

nursing home, the patient remains

responsible for payment of the nursing

home’s room and board charges.

If, however, a patient receiving

Medicare hospice benefits in a nursing

home is also eligible for Medicaid,

Medicaid will pay the hospice at least

95 percent of the State’s daily nursing

home rate, and the hospice is then

responsible for paying the nursing home

for the beneficiary’s room and board.

The specific services included in the

daily rate payment are determined by a

State’s Medicaid program and may vary

from State to State.

In addition to the room and board

payment, a hospice may contract with

the nursing home for the nursing home

to provide non-core hospice services

(i.e., those services which the hospice is

not required by law to provide itself) to

its hospice patients.

Vulnerabilities in Nursing Home

Arrangements With Hospices

Hospice services may be appropriate

and beneficial to terminally ill nursing

home residents who wish to receive

palliative care. However, arrangements

between nursing homes and hospices

are vulnerable to fraud and abuse

because nursing home operators have

control over the specific hospice or

hospices they will permit to provide

hospice services to their residents. An

exclusive or semi-exclusive arrangement

with a nursing home to provide hospice

services to its residents may have

substantial monetary value to a hospice.

In these circumstances, some nursing

home operators and/or hospices may

request or offer illegal remuneration to

influence a nursing home’s decision to

do business with a particular hospice.

Hospice patients residing in nursing

homes may be particularly desirable

from a hospice’s financial standpoint.

First, a nursing home’s population

represents a sizeable pool of potential

hospice patients. Second, nursing home

hospice patients may generate higher

gross revenues per patient than patients

residing in their own homes because

nursing home residents receiving

hospice care have, on average, longer

lengths of stay than hospice patients in

their homes. Also, there may be some

overlap in the services that the nursing

homes and hospices provide, thereby

providing one or the other the

opportunity to reduce services and

costs. A recent OIG report found that

residents of certain nursing homes

receive fewer services from their

hospice than patients in their own

homes. Since hospices receive a fixed

daily payment regardless of the number

of services provided or the location of

the patient, fewer services may result in

higher profits per patient.

However, a hospice’s access to

nursing home patients depends on the

nursing home operator. Nursing home

operators may restrict residents to one

or two hospice providers. While an

exclusive or semi-exclusive arrangement

can promote efficiency and safety by

permitting the nursing home operator to

coordinate care, screen hospice

caregivers, and maintain control of the

premises, it also enhances the value of

the nursing home operator’s decision. In

these circumstances, some nursing

home operators or hospices may request

or offer illegal inducements to influence

the selection of a hospice.

Paying or Receiving Kickbacks in Order

to Induce Medicare or Medicaid

Referrals

Because kickbacks can distort medical

decision making, result in

overutilization, and have an adverse

effect on the quality of care patients

receive, they are prohibited under the

Federal health care programs, including

Medicare and Medicaid. Under the antikickback statute, it is illegal to

knowingly and willfully solicit, receive,

offer, or pay anything of value to induce

referrals of items or services payable by

a Federal health care program.

The OIG has observed instances of

potential kickbacks between hospices

and nursing homes to influence the

referral of patients. In general, payments

by a hospice to a nursing home for

‘‘room and board’’ provided to a

Medicaid hospice patient should not

exceed what the nursing home

otherwise would have received if the

patient had not been enrolled in

hospice. Any additional payment must

represent the fair market value of

additional services actually provided to

that patient that are not included in the

Medicaid daily rate.

Specific practices which are

suspected kickbacks include:

• A hospice offering free goods or

goods at below fair market value to

induce a nursing home to refer patients

to the hospice.

• A hospice paying ‘‘room and board’’

payments to the nursing home in

amounts in excess of what the nursing

home would have received directly from

Medicaid had the patient not been

enrolled in hospice.

• A hospice paying amounts to the

nursing home for ‘‘additional’’ services

that Medicaid considers to be included

in its room and board payment to the

hospice.

• A hospice paying above fair market

value for ‘‘additional’’ non-core services

which Medicaid does not consider to be

included in its room and board payment

to the nursing home.

• A hospice referring its patients to a

nursing home to induce the nursing

home to refer its patients to the hospice.

• A hospice providing free (or below

fair market value) care to nursing home

patients, for whom the nursing home is

receiving Medicare payment under the

skilled nursing facility benefit, with the

expectation that after the patient

exhausts the skilled nursing facility

benefit, the patient will receive hospice

services from that hospice.

• A hospice providing staff at its

expense to the nursing home to perform

duties that otherwise would be

performed by the nursing home.

Parties that violate the anti-kickback

statute may be criminally prosecuted or

subject to civil monetary penalties, and

also may be subject to exclusion from

the Federal health care programs.

What To Do if You Suspect Fraud

Involving Arrangements Between

Nursing Homes and Hospices

If you have information about nursing

homes and hospices engaging in any of
Federal Register / Vol. 63, No. 79 / Friday, April 24, 1998 / Notices 20417

the activities described above, contact

any of the regional offices of the Office

of Investigations of the Office of

Inspector General, U.S. Department of

Health and Human Services, at the

following locations:

Field offices States served Telephone

Boston ..................................................... MA, VT, NH, ME, RI, CT .......................................................................................... 617–565–2660

New York ................................................ NY, NJ, PR, VI ......................................................................................................... 212–264–1691

Philadelphia ............................................ PA, MD, DE, WV, VA, DC ....................................................................................... 215–861–4586

Atlanta ..................................................... GA, KY, NC, SC, FL, TN, AL, MS ........................................................................... 404–562–7603

Chicago ................................................... IL, MN, WI, MI, IN, OH, IA, MO ............................................................................... 312–353–2740

Dallas ...................................................... TX, NM, OK, AR, LA, CO, UT, WY, MT, ND, SD, NE, KS ..................................... 214–767–8406

Los Angeles ............................................ AZ, NV, So. CA ........................................................................................................ 714–246–8302

San Francisco ......................................... No. CA, AK, HI, OR, ID, WA .................................................................................... 415–437–7960

To Report Suspected Fraud, Call or

Write

1–800–HHS–TIPS (1–800–447–8477),

Department of Health and Human

Services, Office of Inspector General,

P.O. Box 23489, L’Enfant Plaza Station,

Washington, D.C. 20026–3489.

Dated: April 15, 1998.

June Gibbs Brown,

Inspector General.

[FR Doc. 98–10907 Filed 4–23–98; 8:45 am]

BILLING CODE 4150–04–P

DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Substance Abuse and Mental Health

Services Administration

Agency Information Collection

Activities: Submission for OMB

Review; Comment Request

Periodically, the Substance Abuse and

Mental Health Services Administration

(SAMHSA) will publish a list of

information collection requests under

OMB review, in compliance with the

Paperwork Reduction Act (44 U.S.C.

Chapter 35). To request a copy of these

documents, call the SAMHSA Reports

Clearance Officer on (301) 443–7978.

Substance Abuse Prevention and

Treatment Block Grant Application

Format: FY 1999–2001—0930–0080

(Revision)—The Public Health Service

Act (42 U.S.C. 300x21–35 & 51–64)

authorizes block grants to States for the

purpose of providing substance abuse

prevention and treatment services.

Under the provisions of the law, States

may receive allotments only after an

application is submitted and approved

by the Secretary, DHHS. For the FY

1999 Substance Abuse Prevention and

Treatment (SAPT) Block Grant cycle,

SAMHSA will provide States with

slightly modified application forms and

instructions. These changes affect the

portion of the application that asks for

information related to section 1926

(sales of tobacco to minors). The

application no longer requires a

description of sampling methodologies

and procedures for identifying and

selecting tobacco outlets to be sampled

throughout a State, unless a change to

such methodologies or procedures has

occurred in the previous year. The

application provides for more detailed

information on the results and validity

of the random unannounced

inspections, and it will request greater

detail on the number and results of

actual enforcement activities that a State

has undertaken. At the request of the

Department, SAMHSA is including an

additional tobacco-related question in

Attachment 6 of the application. This

question requires States to briefly

describe collaboration between each

State’s Tobacco and Health Office

(ASTHO representative) and Single

State Authority for Substance Abuse

(NASADAD representative). Because

Federal funds for tobacco prevention

and control efforts are, in most cases,

awarded to different State-level

agencies, it is necessary for the

Department and SAMHSA to verify and

understand interactions at the State

level on youth tobacco prevention and

enforcement. SAMHSA has modified

the race/ethnicity categories in Form 9

to comply with recent revisions to OMB

Directive No. 15. These modifications

are not expected to increase respondent

burden.

The annual burden estimate for the

SAPT Block Grant Application Format

is shown below:

Number of

respondents

Responses

per

respondent

Hours per response Total hours

11 .................................................................................................................................................. 1 530 530

59 .................................................................................................................................................. 1 563 33,217

Total ...................................................................................................................................... ........................ ........................ 33,747

1 Red Lake Indian Tribe (exempt from Tobacco Regulation requirements).

Written comments and

recommendations concerning the

proposed information collection should

be sent within 30 days of this notice to:

Daniel Chenok, Human Resources and

Housing Branch, Office of Management

and Budget, New Executive Office

Building, Room 10235, Washington,

D.C. 20503.

Dated: April 17, 1998.

Richard Kopanda,

Executive Officer, SAMHSA.

[FR Doc. 98–10921 Filed 4–23–98; 8:45 am]

BILLING CODE 4162–20–M

DEPARTMENT OF HOUSING AND

URBAN DEVELOPMENT

[Docket No. FR–4349–N–14]

Submission for OMB Review:

Comment Request

AGENCY: Office of the Assistant

Secretary for Administration, HUD.

ACTION: Notice.