The 4th Annual HCCA Healthcare Enforcement Compliance Conference was held in Washington D.C. during the mid-term election week this year. In a time of political divide, there was no such discourse amongst the 400 legal and compliance professionals that gathered to hear from many government agencies including OIG, DOJ, CMS, and more. Those who attended were highly focused on committing their talents and efforts to help their healthcare organization stay compliant with various state and federal laws, and regulations. The sentiments were clear: protecting the integrity of the federal healthcare program dollars and quality of necessary care provided to beneficiaries are essential to good governance.

Over the three-day conference, attendees were able to hear directly from government enforcement officials on current trends and success stories of enforcement of fines and penalties for healthcare fraud and abuse. Collegiality and coordination were clearly the themes of this year’s conference. It’s important to recognize the enhanced and coordinated efforts of federal, state, and local law enforcement agencies to pursue and prosecute fraud, waste, and abuse of federal healthcare program dollars.

There are many new healthcare fraud strike forces focusing on opioid abuse, unnecessary care, fraudulent billing practices, and elaborate fraud schemes. Please continue reading to gain a broader scope of the conference and some of the important takeaways for healthcare Compliance, HR, and Legal professionals. 

HHS Office of Inspector General (OIG) Update

The conference kick-off speaker was Gregory Demske, Chief Counsel to Inspector General HHS OIG. Mr. Demske explained that the Office of Inspector General (OIG) for the Department of Health and Human Services (HHS) is the largest such Office of Inspector General (OIG) in the federal government with 1,600 employees.

The office is responsible for oversight of over $1 trillion of federal tax dollar programs. HHS OIG has caught 18,222 excluded individuals or entities as well as presented 3,221 civil actions against such individuals or entities from 2013-2017.

Mr. Demske presented the HHS OIG’s top priorities during this year’s conference. These priority areas are consistent with the latest version of the OIG’s 2018 Semiannual Report to Congress.

2018 HHS Office of Inspector General (OIG) Top Priorities

Opioid Abuse and Fraud

  • Opioid-related exclusions in 2017 equaled 587 individuals (the majority being nurses)
  • The role of the OIG in combatting the opioid epidemic
  • Identifying wrong-doers and holding them accountable
  • Collaboration with partners and agencies
  • HHS program improvements

Home and Community-Based Services

  • Home Health
  • Hospice
  • Group Homes
  • Personal Care Services

Skilled Nursing Facilities

  • Failure to report abuse/neglect
  • Grossly substandard care
  • Disaster preparedness
  • Unnecessary therapy

Managed Care

  • Provider impact on patients and programs
  • Health plans patient access to services, payment denials, and risk adjustments

Audits

  • Focused on quality and safety
  • Compliance reviews for HHAs, hospitals, hospice centers, skilled nursing facilities
  • Medicare Part B (ambulance, orthotics, psychotherapy, etc.)
  • Medicare Part C (RADV)

Medicare Fraud Strike Forces

  • Regional U.S. locations
  • Increased data analytics and special investigations
  • Combined resources of federal and state law enforcement

Government Agencies Collaborate to Combat Healthcare Fraud

During this year’s conference, we heard a lot about agency collaboration involving providers and each government entity working to combat healthcare fraud. Alec Alexander, Deputy Administrator and Director of the Center for Program Integrity (CPI), presented during the conference and was eager to offer transparency and ways to help provide feedback by sharing email contact information for each of the CPI Group Directors.

The CPI was formed at the direction of the Department of Health and Human Services (HHS) Secretary in March of 2010 to align the Medicare and Medicaid program integrity activities. They now have allocated 492 FTEs broken up into eight groups and 24 divisions including four field offices. Their total budget is over $1.3 billion each year and Mr. Alexander explained their mission is to take the $1.3 billion budget and protect the $1 trillion of Medicare and Medicaid spending; the least burdensome way possible. He also stated that when the burden is applied, it must be done fairly and efficiently. 

The CPI serves as the Center for Medicare and Medicaid Services (CMS)’s focal point for all national and statewide Medicare and Medicaid program integrity functions.

The 2018/2019 CPI Priority areas include:

  • Invest in data and analytics to support fraud detection and prevention efforts
  • Reduce provider burden
  • Strengthen collaboration with all our partners
  • Enhance Medicaid oversight
  • Combat the opioid crisis
  • Integrate vulnerability management

One of the most interesting areas that Mr. Alexander discussed was the strengthening of collaboration with all enforcement partners in what he referred to as “the enforcement continuum”. This initiative has resulted in the creation of the MCC – Major Case Coordination. The group makes decisions as to whether a provider has made an error, or if there is intent associated with a crime. The simple goal of the MCC is to utilize the right tool, for the right case, at the right time, and in the right order. Mr. Alexander shared some interesting statistics about the MCC including the following:

726 Cases Reviewed as of 10-5-18

  • 354 Law enforcement referrals
  • 167 Revocations
  • 225 Payment suspensions
  • 18 Education cases

MCC Success Story 

  • Less than 45 days from MCC meeting to an indictment
  • 5/16/18 MCC meeting
  • 6/26/18 Indictment

Another partnership that Mr. Alexander highlighted is the Healthcare Fraud Prevention Partnership (HFPP), which is a voluntary group made up of a public-private partnership with the goal of identifying and reducing fraud, waste, and abuse across the healthcare sector.

The HFPP consists of 113 partners as of October 2018 including the following:

  • 9 Federal Agencies – 8%
  • 12 Associations – 11%
  • 30 State/Local Partners – 27%
  • 61 Private Payers  54%

HCCA Enforcement Conference Takeaways

The U.S. Opioid Epidemic Requires Enhanced Government Collaboration

  • Agencies are partnering together for quicker and more efficient investigations and indictments
  • There are more resources both money and people focused on the opioid epidemic
  • Watch for inter-related prosecutions and settlements (OIG calls them spin-offs)

The HHS Office of Inspector General (OIG) Healthcare Exclusion 2018 Focus

The HHS OIG continues to exclude people at an increasing rate. Over 2300 persons and entities have been excluded in 2018.

Four broad categories that are factors in exclusion decisions include:

  • Nature and circumstance of conduct
  • Conduct during the government’s investigation
  • Significant improvement efforts
  • History of compliance

Important Information for HR to Consider when Hiring

  • Check all former names – not knowing a former name isn’t an excuse for missing an exclusion
  • During the hiring process make sure you ask questions if someone has previously practiced in another state. Why did they leave? Do they have a licensure issue? 

Did you know?

The number one exclusion type is due to revocation, loss, or suspension of a healthcare license?

The most frequent excluded person is a nurse, and the second largest number are nursing assistants?

A growing number of exclusions are due to default on a federal student loan?


HHS Office of Inspector General Releases a New False Claims Act Fraud Risk Indicator 

The HHS Office of Inspector General (OIG) released a new section of their website to help provide a rating system and assessment of the future risk posed by persons who have allegedly engaged in civil healthcare fraud.

The HHS OIG Fraud Risk Indicator will add a new level of transparency in False Claims Act (FCA) investigations as the names of organizations with OIG settlements will be placed online with an associated risk category.  The Risk Categories involved are categorized below:

  • Highest Risk – Exclusion
  • High Risk – Heightened Scrutiny
  • Medium Risk – Corporate Integrity Agreements (CIAs)
  • Lower Risk – No Further Action
  • Low Risk – Self Disclosure

HHS OIG Fraud Risk Indicator

 

ProviderTrust Team

Our team once again had a blast at the HCCA Enforcement Conference, getting to learn from so many informative sessions, and having the opportunity to meet peers in the industry. 

At ProviderTrust, we know collaboration is key and we focus on processes to reduce your burden so you can focus on people to ensure quality outcomes for your organization.

Please let us know if you have any questions, or feel free to leave a comment below – we always love a good dialogue!


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Written by Michael Rosen, ESQ

ProviderTrust Co-Founder, mrosen@providertrust.com

Michael brings over 20 years of experience founding and leading risk mitigation businesses, receiving numerous accolades such as Inc. Magazine’s Inc. 500 Award and Nashville Chamber of Commerce Small Business of the Year.

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