Office of Inspector General Offers Guidance in Addressing Healthcare Fraud Risk

In yesterday’s post, we introduced a recent effort by the U.S. Department of Health and Human Services’ Office of Inspector General, along with several healthcare advocacy groups and agencies, designed to inform and educate healthcare governing boards as to the importance of maintaining thorough compliance measures. We looked at the heightened expectations and standards imposed upon governing boards, as well as the various roles and relationships the OIG considers essential components of a well-run healthcare organization.

In today’s post, we will conclude our review of the report by discussing the ways in which companies are encouraged to identify and audit potential risk areas, as well as ways in which governing bodies can encourage accountability across the spectrum of their organizations.

Identifying risk areas

Healthcare fraud is a rampant problem in the United States and it often presents itself in the billing department. There are a number of ways in which a facility or practitioner can defraud the government, including upcoding, billing for services never rendered, or performing medically unnecessary tests or procedures.

In its report, the OIG encouraged governing boards to adopt a culture of compliance as a “way of life.” It also included several examples of this measure, including:

  • Regular employee performance reviews;
  • Evaluations of department-level compliance and consistency;
  • Mandatory participation in annual incentive programs;
  • Employee and executive recoupment if compliance is not met;
  • Mandatory certification of compliance by employees other than those engaged in the compliance department.

From there, the OIG identified several key reasons why governing boards should be incentivized to implement proper compliance protocol. First, it reminded readers of the ever-present 60-Day Rule, which requires healthcare providers to promptly return overpayments to Medicare or Medicaid within 60 days of when the mistake is identified. The report then suggested that boards could inquire as to the protocol in place when a mistake is identified, which would quickly inform the board as to whether proactive measures are in place or if additional help is needed.

Benefits of self-reporting

In its concluding section, the report discusses the benefits of self-reporting instances of billing error or intentional fraud. In recognizing that many organizations engage in internal analyses of whether self-reporting is in the company’s financial best interests, the OIG suggested that following its Self-Reporting Protocol is beneficial for the following reasons:

  • Faster resolution of the matter;
  • Lower payments (i.e., 1.5 times damages, as opposed to double or treble damages);
  • Exclusion release as part of the settlement, with strong likelihood that no corporate integrity agreement will be required.

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By | 2018-09-14T14:17:42+00:00 May 8th, 2015|Healthcare Fraud|