Compliance is a tough job. It is thankless and often seen as the watchful eye. However, if ever there was a time to highlight the importance of compliance in healthcare, 2017 is the time. Why? Well, just look at it from the perspective of the OIG or Department of Justice (DOJ).
The OIG reported that in 2016, fraud and abuse was the number one problem facing healthcare when it comes to fines and punishment. Cases stemming from False Claims Act, poor quality of care, fraudulent billing, and Stark violations dominated the news. In the latest report on Fraud and Abuse in 2016, the combined efforts of the HHS OIG and DOJ won or negotiated over $2.5 billion in health care fraud judgments and settlements 2 , and it attained additional administrative impositions in health care fraud cases and proceedings. As a result of these efforts, as well as those of preceding years, in FY 2016 over $3.3 billion was returned to the Federal Government or paid to private persons.
In FY 2016, investigations conducted by HHS’ Office of Inspector General (HHS-OIG) resulted in 765 criminal actions against individuals or entities that engaged in crimes related to Medicare and Medicaid, and 690 civil actions, which include false claims and unjust-enrichment lawsuits filed in federal district court, civil monetary penalties (CMP) settlements, and administrative recoveries related to provider self-disclosure matters. HHS-OIG also excluded 3,635 individuals and entities from participation in Medicare, Medicaid, and other federal health care programs. Among these were exclusions based on criminal convictions for crimes related to Medicare and Medicaid (1,362) or to other health care programs (262), for patient abuse or neglect (299), and as a result of licensure revocations (1,448). HHS-OIG also issued numerous audits and evaluations with recommendations that, when implemented, would correct program vulnerabilities and save program funds.
The Federal Strike Forces and their combined efforts to find and prosecute healthcare fraud were in high gear. Settlements totaling billions of dollars show the fruits of their labor. Alongside that, the OIG Work Plan for 2017 is another indication of what the regulators are focusing on and how your organization should be gearing up to remain compliant and out of hot water.
So, why is it so hard for the Compliance Department in some organizations to be heard during budget time?
To us, it seems to start from the top of the organization. Ask yourself, does your CEO believe in and make compliance a part of your company culture? What specifically does he/she do each week or even once a month to highlight the importance of your plan?
If your organization is led by senior management (and by the way, one way to tell is if YOUR role as Compliance Officer is considered on the senior management team), then getting noticed and probably funded for the compliance needs is probably much easier. If, however, your senior managers don’t live and breathe, or even act consistent with the company values as well as compliance plan, then your job just got that much harder.
A penny spent can be many dollars saved:
Good compliance governance realizes that money and resources will need to be spent and allocated in order for compliance to do its job effectively. For every dollar spent on preventing and educating on compliance, your organization saves on possible and preventable fines and penalties.
Take exclusions for example:
The OIG and CMS all agree that monthly monitoring for exclusions is a must. The various federal (OIG-LEIE, SAM.gov, and available state Medicaid exclusion lists) are updated throughout each month. The fines and penalties are clearly established for hiring or contracting with an excluded individual and/or entity. They can include up to $10,000 for each item claimed for reimbursement times three and/or the salary and benefits of the excluded person for the time your organization billed for federal healthcare reimbursements (Medicare, Medicaid, TriCare, CHIPS) times three.
NOTE: If your compliance plan includes self-disclosure when the exclusion is found, then the multiplier can be reduced to 1.5 x.
There are many other examples of effective compliance budget planning, but this blog will highlight one additional one: Training.
What is Trained is What is Learned:
Training needs to be effective and documented. Without effective compliance training, your staff will not know the very basics of compliance that you are otherwise holding them accountable. Ensure that you have training and continuing education on the key elements of your plan as well as new rules or regulations that come up in the industry.
Training is one of the first things an OIG investigator and/or Dept. of Justice prosecutor will look at to consider what is the pulse and culture of your organization. Be sure to include a hotline as a place for people to report suspected fraud. A whistleblower is, in most cases, preventable with such lines of communication and follow through.
Fight hard and stand your ground. Remember, you are there to protect the company, its employees and the safety of your patients through effective compliance. You too can be the rock star of your corporate family.
Written by Michael Rosen, ESQ
ProviderTrust Co-Founder, firstname.lastname@example.org
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.