Top 3 OIG Exclusion Reasons to Self-Disclose to the OIG

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You might hesitate to self-disclose fraud and exclusions to the OIG due to the time investment and immediate fines. However, according to the OIG, the process does not take as long as you might think.

On average, the self-disclosure process from beginning to end takes just 12 months.  When you consider the benefits of a self-disclosure, including the potential for reduction in civil fines and penalties, the process and time to navigate through it is not a long road.

In April of 2013, the OIG issued an updated Self-Disclosure Protocol, which stressed the advantages of disclosing violations rather than having the OIG sniff them out. Self-disclosing beats having the OIG pursue your organization in a False Claims Act violation, fraud investigation or other related infractions.

The advantages to self-disclosing might surprise you. Take a look at these top 3 OIG exclusion reasons to self-disclose to the OIG:

  1. Self-reporting would presumptively indicate an effective compliance program, removing the need for a Corporate Integrity Agreement (CIA) to get involoved. As a result, you’ll see reduction in major and unnecessary expenses that come with complying with the burdens required by a CIA. (I have heard from healthcare companies which are under a CIA that expenses can reach over $10,000 per month for an outside consultant and/or hire. This does not include internal expenses to comply, added audit and monitoring expenses).
  2. The OIG formalized the process of reducing the multiplier of damages from 3 to 1.5.  (3 times is the amount typically assessed if the OIG initiates the investigation/case).
  3. The May Special Advisory on the effect of exclusions and self-disclosure issued by the OIG discussed the broad reach of its decisions to exclude providers from federal healthcare programs. In some cases, this decision can add fines for paying administrative and management services even if they do not directly relate to patient care. Not to mention, the potential that healthcare organizations can face civil liability if an excluded person/entity submits claims to a federal healthcare program. (Note: The pending bill introduced by the sub-committee on Health in August grants the OIG expanded authority, including the ability to execute those affiliated with a provider/individual found with an OIG sanction for fraud (eg., billers and owners). This bill seems to be intended to punish excluded executives or owners because of the association of Medicare fraud and profiting from federal healthcare dollars (eg. CMS, TriCare, CHIPS).

Lately, federal authorities have expanded their efforts to investigate healthcare companies for fraud. With the advent of the Affordable Care Act kicking into high gear in the coming months, scouting out cases to prosecute for fraud will get easier and easier. Claiming reimbursement from federal healthcare dollars (CMS) for services rendered by or items claimed for services or equipment by an excluded person or entity is the low hanging fruit for enforcement of serious civil fines and penalties. See how Middle Tennessee, home to so many healthcare management firms is expanding their investment in investigations and enforcement. 

Since its inception in March 2007, Medicare Fraud Strike Force operations in nine locations have charged more than 1,500 defendants who collectively have falsely billed the Medicare program for more than $5 billion. In addition, the HHS Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

Learn more about the Health Care Fraud Prevention and Enforcement Action Team (HEAT).

Remember: If you discover that you have billed CMS for services of an excluded individual or entity (check the OIG List of Excluded Individuals and Entities/LEIE) and/or submitted a false claim, by following the OIG Self-Disclosure protocol you may reduce your civil fines and penalties from a multiplier of 3x to 1.5x. Although it’s never fun to tattle-tell on yourself, following best practices certainly has its advantages.

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