Healthcare Compliance 1 – (Health Information Management) 1. There are numerous entities to which a healthcare organization might choose to voluntarily dis

Healthcare Compliance 1 – (Health Information Management) 1. There are numerous entities to which a healthcare organization might choose to voluntarily dis

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Healthcare Compliance 1 – (Health Information Management) 1. There are numerous entities to which a healthcare organization might choose to voluntarily disclose Medicare or Medicaid billing errors. Name four of them.

2. Under the False Claims Act, there is a tangible benefit to an organization that discloses a violation within 30 days of becoming aware of it. What is the benefit?

3. Use the Medicaid Fraud Control Unit annual reports that can be found at https://oig.hhs.gov/ to determine which reviewed state has the highest and lowest convictions, civil judgments and settlements, as well as the amount of recovery. 

Review 20 state reports to retrieve the data. 

a) Create a spreadsheet or table to show the convictions, civil judgments and settlements, and amount of recovery for each state.

b). Identify the following:  

– State with the highest number for each category

– State with the lowest number for each category

– Average number for each category Chapter 12

Repayments and Disclosures

Learning Objectives

Circumstances when disclosure and repayment might make sense

Government agencies for disclosures

Legal bases for duty to disclose and repay

Benefits and disadvantages of self-disclosure

Importance of advice of legal counsel

Process for conducting a self-disclosure

Differences between OIG SDP and Stark SRDP

Introduction

Self-disclosure may be indicated by a report of non-compliance, a routine internal audit, or the discovery of a billing error in the normal course of business.

Self-disclosure may be directed to the CMS, a CMS intermediary or carrier, the OIG, the DOJ, the FBI, a state Medicaid Fraud Control Unit, or a state agency responsible for provider licensing.

Legal Bases for Repayment and Disclosure

Patient Protection and Affordable Care Act (PPACA)

False Claims Act (FCA)

Stark Physician Self-referral Law

Anti-Kickback Statute (AKS)

Health Insurance Portability and Accountability Act (HIPAA)

Patient Protection and Affordable Care Act (PPACA)

Overpayment reported and returned within 60 days of identification.

Patient co-payments returned as well.

Disclosures and repayments submitted to Medicare “affiliated carrier”.

False Claims Act (FCA)

Reduce treble damages for false claim to double damages by disclosing violation within 30 days of learning about it.

“Reverse false claim”: a violation for a person or organization to make a fraudulent statement in order to avoid or reduce an “obligation” to make a payment to the federal government.

Stark Physician Self-referral Law

The Self-Referral Disclosure Protocol (SRDP) was created in 2010 and applies only to the Stark Physician Self-referral Law.

It is used to resolve overpayment liability exposure resulting from a violation.

Detailed information about the violation and the entity’s compliance program is submitted to CMS.

In response, the CMS “may” reduce any overpayments owed due to the violation.

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Anti-Kickback Statute (AKS)

In 1998, the OIG issued a Self-Disclosure Protocol (SDP) to be used to report overpayments connected with the AKS or both the AKS and the Self-Referral Law.

Overpayments related to the Self-Referral Law alone are handled through the SRDP.

Offers opportunity to reduce the severe penalties associated with AKS violations.

Health Insurance Portability and Accountability Act (HIPAA)

In the landmark ETHC case, federal government brought criminal charges for failure to refund overpayments related to HIPAA.

Case involved overpayments from private payors and individual patients, akong with Medicare and Medicaid.

Benefits of Self-Disclosure

More congenial, less adversarial relationship with the enforcement officials

More influence over the conduct of the government investigation

Reduced likelihood of subpoenas or search warrants

Reduced penalties for a FCA violation

Less likely that government will prosecute

Less onerous terms of any settlement

Disadvantages of Self-Disclosure

Violation incident might never be discovered

Many “benefits” are not guaranteed

Other misconduct and violations may be revealed

Minor event may become larger, more serious, and more expensive

Government may view incident more seriously and impose harsher penalties, including as CIA

Carrying Out a Self-Disclosure

To which agency to self-disclose

Determine which protocol to use

OIG Self-Disclosure Protocol (SDP)

Stark Self-Referral Disclosure Protocol (SRDP)

Disclosure submission process

Details to be included with disclosure

Possible agency responses to disclosures

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