Healthcare providers constantly find themselves faced with new and increasing compliance enforcement threats. Subsequently, they have a responsibility to continuously monitor their practices and ensure claims filed to Medicare and other health insurance payers are accurate.
In order to avoid civil monetary penalties and other fines, healthcare providers need to consider various ways to prevent potential sanctions. To begin with, they should conduct systematic self-audits to detect fraudulent claims or errors. If an error is discovered, the healthcare provider should investigate the conduct that leads to it, quantify the damages, and consider self-reporting to the Office of Inspector General (OIG). Providers can voluntarily disclose potential fraud with respect to Federal healthcare programs by following the Self-Disclosure Protocol (SDP) issued by the OIG.
OIG’s Self-Disclosure Protocol
The OIG has set up the Self-Disclosure Protocol to help healthcare providers identify, disclose and resolve instances of potential fraud that involve federal healthcare programs. However, its purpose is not to address mistakes, errors, or negligence. Only after providers determine that fraudulent activity is ongoing within the organization, they need to contact the OIG and follow the Self-Disclosure Protocol instructions carefully.
The Self-Disclosure Protocol for excluded individuals requires:
- Identification of the excluded parties;
- Provider ID number;
- Excluded individuals’ job duties;
- Dates of their employment or under contract;
- A description of any background checks completed before and/or during the time excluded individuals were employed or under contract;
- A description of the provider’s screening process;
- Circumstances leading to the engagement of the excluded individual;
- A description of how the situation was discovered;
- A description of corrective action taken; and
- The total amount claimed and paid by the federal health care program for services of the excluded party.
In addition to gathering the information listed above, healthcare providers need to screen all current employees and contractors against the OIG’s List of Excluded Individuals and Entities (LEIE) before submitting information to the OIG.
Reasons for Self-Disclosing to the OIG
Although the OIG does not guarantee a particular result, there are advantages of voluntary disclosure.
Avoiding Corporate Integrity Agreement
As a result of a federal law violation, the OIG may require healthcare providers to enter into a Corporate Integrity Agreement (CIA). While under a CIA, the healthcare provider is usually required to implement a comprehensive employee training program, a confidential disclosure program, written standards, and policies, and designate a compliance officer. However, if healthcare organizations choose to use the Self-Disclosure Protocol, they might avoid the requirement of a CIA with rigorous reporting, auditing, and continuing compliance obligations.
If the OIG determines that healthcare providers have committed Medicare fraud and have received overpayments as a result, they are not only required to pay back the amount of the overpayment but the overpayments or damages are multiplied by different amounts. On the other hand, if healthcare providers use the Self-Disclosure Protocol, the OIG allows them to pay damages multiplied by a minimum of 1.5., as opposed to a multiplier of 3 which would normally be required.
Reducing Costs of an Investigation
Going through a Medicare fraud investigation can be a significant burden for healthcare organizations because it takes a long time and leaves a healthcare provider in a difficult position. Once providers voluntarily disclose potential fraud and self-disclose, the OIG is committed to investigating and resolving issues more swiftly, allowing providers to move past the violation faster and lower the cost of the investigation. Also, in case of any overpayments from Medicare or other federal payers, providers are required to return them immediately. However, if the healthcare provider opts to use the Self-Disclosure Protocol, this obligation is suspended while the claims are being investigated, provided the Protocol is filed and received on time.Prevent any failure to comply with the healthcare laws and regulations and find out how to prepare for increasing compliance enforcement threats with this detailed guide on exclusion screening.
Effects of Self-Disclosure
Since federal authorities continue to expand their efforts to investigate healthcare companies for fraud, providers should be prepared to take advantage of OIG’s voluntary disclosure program. Self-disclosing to the OIG remains a relatively efficient means of resolving liabilities and avoiding penalties for healthcare providers who discover compliance problems, want to correct them, and repay any overpayments. However, providers must be aware that even good-faith disclosure and cooperation with the OIG cannot guarantee freedom from mandatory exclusion or an investigation by the OIG regarding unrelated noncompliance discovered during disclosure. While there are a number of benefits, a healthcare provider should always conduct a thorough investigation before determining if the Self-Disclosure Protocol is the right option for resolving the issues.
Having an efficient compliance plan, which includes auditing and reviewing internal practices, helps healthcare providers in minimizing potential compliance problems and the need to self-disclose in the first place. Healthcare monitoring is a complex process, which is why organizations should integrate technology into their compliance programs. With an automated exclusion screening solution, healthcare providers ensure medical data privacy and security, improve accuracy and risk management, and keep their company OIG compliant without any difficulty.