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Settlement Considerations: CIA or No CIA?
Settlement Considerations: CIA or No CIA?

We are pleased to welcome a guest today on the blog - Harold Malkin, a former Assistant U.S. Attorney who specialized in the resolution of civil healthcare fraud cases involving individual providers, medical practices and institutional providers in the Western District of Washington in Seattle for over 15 years. In this article, Harold will highlight some important information regarding the permissive and mandatory exclusion authority of the Office of Inspector General (OIG) as well as some things to consider if you find yourself in settlement discussions with OIG.

Hospital Vendor Credentialing – What is It?
Hospital Vendor Credentialing – What is It?

“Credentialing” is a word with many meanings in healthcare. Hospitals are required to do certain checks on physicians, vendor reps. and vendor companies that all fall under this vague realm of credentialing.  Physicians go through a credentialing process, which is a review of their education, training, residency, certifications and licensure. If a hospital is billing Medicare and/or Medicaid, this process should also include screening against the OIG-LEIE, SAM, and all State exclusion lists to ensure the physician is not excluded by one or more of these agencies.  A second level of credentialing focuses on vendor representatives who visit various areas of a hospital. This generally includes some level of verification of certain immunizations, certifications (i.e. CPR), and a training component. The representative must check in at a hospital to verify they have been appropriately credentialed, then will be given a badge defining which areas of the hospital they have access to.

OIG Compliance Program Guidance For Hospitals
OIG Compliance Program Guidance For Hospitals

I could sit here and list all seven elements of a compliance program but there is so much more to a compliance program than just providing a step-by-step guideline. A compliance program is something that works specifically for YOU and your company alone. There is a point where one can only make suggestions. After all, nothing is one-size-fits all anymore. Here are highlights of some of the elements along with some important factors to consider when developing a compliance program.  OIG Compliance Program Guidance -  1. Fraud and Risk Areas  According to the OIG’s Supplemental Compliance Guidance for Hospitals one of the first steps for a OIG compliance program guidance for hospitals is recognizing areas in the company that can lead to fraud and induce risk. Such as: submission of accurate claims and information, referral statues, payments to reduce or limit services, the Emergency Medical Treatment and Labor Act (EMTALA), substandard care, relationships with Federal health care beneficiaries, HIPAA Privacy and Security Rules, and billing Medicare or Medicaid substantially in excess of usual charges.

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