Office of Inspector General Offers Guidance in Avoiding Illegal Billing Practices

On April 20, 2015, the DHHS OIG, along with the Association of Healthcare Internal Auditors, the American Health Lawyers Association, and the Healthcare Compliance Association, published a first of its kind educational manual designed to help boards avoid the costly and dangerous practices of upcoding, illegal billing, and submitting false claims.

In today’s post, we review the OIG’s expectations of healthcare governing boards, as well as the roles, relationships, and reporting practices expected by OIG of healthcare leadership teams. In a follow-up post tomorrow, we will discuss several suggestions offered by the OIG in terms of identifying potential risk factors for fraud and illegal billing, as well as proposals for encouraging accountability and compliance.

OIG imposes high standards for healthcare governing boards

Healthcare corporate board members are often highly successful, experienced members of the community, chosen for the position based on insight, background, and integrity. Accordingly, the OIG laid out the following expectations of both individual members and governing boards as a whole:

Implementation of a strict corporate information and reporting system;

  • Good faith in the exercise of oversight
  • Reporting protocol in place to ensure the governing board will be made aware of billing problems in a timely manner
  • Use of widely recognized compliance sources as guidelines (e.g., sentencing guidelines and corporate integrity agreements)

From there, the OIG continued to refer to the importance of corporate integrity agreements as a way to ensure subjective compliance with the federal rules, as these agreements would be specifically tailored to the entity’s specific industry or unique needs.

Determining the adequacy of compliance programs

Under the OIG’s guidelines, strong compliance programs are the preeminent component to a well-run healthcare organization, with clear channels of communication between facilities and the governing board being the benchmark of effectiveness. As such, the OIG encouraged boards to review the scope, complexity, and adequacy of their compliance programs in light of the organization’s size, pointing out that the larger the organization, the more expansive the regulatory impact.

In addition to size considerations, healthcare boards should have regular meetings with industry professionals familiar with the various compliance structures applicable to the healthcare field. Moreover, boards are encouraged to place one person with legal or regulatory expertise on the board in order to keep abreast of changes in the law.

Roles and relationships of a well-run healthcare organization

The OIG continued its report by outlining several keep compliance roles that should be maintained by employees in order to avoid false claims and billing errors. These roles include the following:

  • Compliance Function: Individual or group is tasked with identifying areas within the organization that do not comply with legal, policy, or business standards. This function includes employee training and incentivizing staff to follow regulatory mandates;
  • Legal Function: Advice and counsel for boards on the legal risks of its current business structure;
  • Internal Audit Function: Regular internal reviews of controls and frameworks in place, including identification of where additional oversight or board management may be required;
  • Human Resources: Individual or group responsible for recruiting, screening, and hiring high-quality employees;
  • Quality Improvement Function: Group responsible for evaluating and measuring quality within the organization, including recognizing and reporting areas of weakness.

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By | 2018-09-14T14:16:05+00:00 May 7th, 2015|Healthcare Fraud|