>> Hello, again.
I'm the last in the PowerPoint marathon although I like to think that we
at least made our PowerPoint entertaining
and Doctor Tasman [assumed spelling] had some good examples of training in terms
of what not to do for documentation.
So I'm going to in this last 15 minutes I'm going to talk for 15 minutes we're a little over
but that is okay because we have a break built-- n and we'll just sort of take a little bit
of a shorter break and continue on to the law enforcement panel.
I'm going to talk about 2 sort of different topics but they're kind of related
in that first I'll talk about different ways that OIG requests information from providers
and then I'll talk about how providers can disclose information to the OIG
through when you have found like compliance problems in your organization, so,
first, how OIG requests information.
We contact providers for information for a couple of different ways
and what we use depends on the purpose.
Either we are engaged in an investigation an audit or an evaluation.
I'll talk about investigations first.
In an investigation the OIG will typically issue an OIG subpoena.
We may issue an frequently do issue subpoena's to targets of investigations
but we also may need to issue a subpoena to providers who have information relevant
to the investigation of someone else.
So, for example, if we're investigating a physician for billing fraud we may need records
from other healthcare providers that that physician either referred patients to
or treated patients at such as or ordered services or items from like TME providers,
hospitals, radiology centers and the like.
And IG subpoena orders are compels a person or organization to bring information documents
or records to the OIG so it's a documentation subpoena.
Our authority for the subpoena comes from the Inspector General Act.
The Department of Justice also has the ability to issue different kinds of subpoena's
and so those are sometimes also used in a healthcare fraud investigation.
If you're ever serve with a subpoena please do not ignore it.
Failure to respond is considered failure to comply and we can sue
in federal court to enforce a subpoena.
The subpoena itself is a packet of paper that has a cover letter in it
that provides the contact information for the OIG agent who is assigned to the case.
It'll then include information defining the terms
and then list what it is that we're looking for.
If you have questions and providers frequently have questions about what it is
that we're looking for or what the terms and the subpoena mean please contact the agent listed
in the cover letter and they will -- the agent will then contact the attorney involved
in the investigation and we can move forward on answering those questions and getting you to,
you know, getting the subpoena process moving forward.
Aside from our law enforcement activities, however, OIG does a huge amount of audit
and evaluation work and we need information from providers to do that work as well.
Many audits focus on specific providers.
Other audits and our evaluation work focus on looking at some part of the Medicare
or Medicaid program more generally to identify potential system vulnerabilities
and then we will then make recommendations to CMS about how to change the program
or improve program integrity features.
So I'll talk about our audit work first.
The first step in the audit process is the OIG's office of audit services will send a letter
to the provider saying that they are the subject of an audit.
Typically a short time later the auditors will hold an entrance conference with the provider
to explain what we're auditing and the information that we need.
Often times these or sometimes these entrance conferences are conducted in person
with the auditors; these are opportunities for the provider to explain the information
that they have gathered in response to the audit letter and explain any other issues
that you think will be relevant to the audit's work.
At the end of the audit there's typically also an exit conference with the audit team
where they explain the findings and there's an additional opportunity
to talk about the audit with them.
OIG's office of evaluations and inspections can also notify providers by letter
that they have been selected to participate in an evaluation.
OAI's work is generally more a national end scope and so there typically is not a meeting
with providers on the subject of the evaluation they typically will meet more with the program,
the government offices involved in the program that we're auditing.
But needless to say it is important to respond and cooperate when you have been selected
to participate in an audit or an evaluation.
Your participation does help OIG fulfill its mission to combat fraud, waste,
and abuse in the federal healthcare programs.
So now I'll move ot the flipside of the situation and talk
about where providers disclose information to the OIG in order
to resolve liability for problematic conduct.
So, and this is a good place to end sort of the compliance part of this presentation
because we have talked a lot today about the different fraud and abuse laws and about how
to create and maintain an effective compliance program to ensure
that you're in compliance with those laws.
So, really, it is a logical asked question to decide what to talk about what you should do
if you find a compliance problem in your organization.
The answer, and we touched on this a little bit today, is that you should not keep money
from a federal healthcare program that you are not entitled to.
As we heard from CMS they process billions of claims a year
and the program's operate largely based on trust,
trust that providers are appropriately providing care
and appropriately billing the program for that care.
Part of that trust is an obligation to report and return money
that should not have been paid to you.
And in this era of new mandatory compliance programs coming in the future
and the 60 day over-payment requirement disclosing and resolving compliance problems
to the government has never been more important.
OIG has long believed that timely corrective action including self-disclosure is a key
component of having an effective compliance program.
We recognize that disclosing issues to the government is not an easy decision
but it can be more difficult when the government knocks on your door without your invitation.
There is a substantial benefit to taking this stuff to disclosed conduct before we find
out about it or before a whistle-blower tells us about it.
When you disclose a problem in good faith you are demonstrating
that your organization has embraced a culture of compliance and is committed to dealing
with the federal healthcare programs with integrity.
In a disclosure you get to work collaboratively with the government a resolution on the issue.
Now, it may also sound odd to say you get to work collaboratively with the government
when you have disclosed potential fraud conduct but it can happen and does happen
when a provider self-discloses; that provider who self-discloses is
in a very different position than one who's under investigation because of a whistle-blower
or some other lead that we have determined on our own.
Finally, keeping federal healthcare program money over-payments can create additional
liability under the False Claims Act and the Civil Money Penalties Law.
So now that you have found a problem what should you do with it?
As an initial matter it's generally a good idea to get some advice about to confirm that you,
in fact, do have a problem and where to send your problem to.
It can be helpful to get advice from a healthcare attorney or an attorney
that has experience dealing with the healthcare programs and the government on these issues.
If you don't have a lawyer you can contact your MAC as well to get some advice in part
to confirm that you, in fact, have a billing problem.
Issues that are only over-payments or innocent mistakes can be recorded to your contractor
through that normal refund reconciliation process,
and I'm not going to talk about that process here today.
OIG has created its own self-disclosure protocol which I will go into more detail on.
You may also need to report the issue
to your local U.S. Attorney's office depending on the conduct.
And, finally, CMS has a disclosure protocol specifically
for physician's self-referral law or stark law violations.
The bottom line as an initial matter is it's a good idea to get some advice
to choose your best disclosure path for your particular situation.
Here's how to disclose to the OIG.
In 1998 we created the Provider Self-Disclosure Protocol it sets out a process
on how providers can investigate, quantify,
and report problematic conduct in their organization.
Many providers have used the protocol over the last 13 or so years we've recovered
over $270 million in disclosures.
Some of the most common issues that come through the protocol include many of the things
that we have talked about today, billing for services provided by an excluded person,
up-coding of E&M services or DRG up-coding, duplicate billing, alteration of records
that don't support the claim that was filed, and kick-back and stark law violations.
On this last point I will also clarify that the OIG's protocol is appropriate for conduct
that implicates both the kick-back and the stark law.
Stark law only conduct should go to CMS through CMS' self-disclosure process.
The protocol, the OIG's protocol we helpfully use the same word to describe the protocols
so it can get confusing but the OIG's protocol is outlined
in the Federal Register Notice that is on OIG's website.
Some of the most common issues and mistakes that providers have made is in your handout,
tips for success in the OIG's self-disclosure protocol I'm going to highlight 4 issues.
First is carefully think about timing of your disclosure.
We have said in our open letters we have also said that your internal investigation
and damages calculation should either be done when you disclose or we ask
that you make a commitment to be done within 3 months of acceptance; this is to help ensure
that matters move through the protocol in a timely and efficient way.
We have experienced issues in which we receive the letter that says we think we have a problem
and we just wanted to let you know and then there's some difficulty
in getting the matter audit done, the damages quantified, and the resolution done,
so we do ask for this commitment upfront as part of cooperating with the OIG disclosure process.
Second is we ask for a lot of specific information.
The Federal Register Notice goes into great detail about what we are looking for.
The open letter also provides additional detail of what we're interested in.
Please provide all of the information we request.
Incomplete submissions can delay the process and can result
in the matter being removed from the protocol as well.
Third is please respond promptly to requests for more information.
We do ask and frankly expect cooperation in the disclosure process as a condition
of being in the disclosure process.
And fourth, I would avoid arguing that no fraud has occurred.
The purpose of OIG's protocol is for providers to disclose conduct
that they have identified as potential fraud liability.
Now, what does that mean?
It means that if, you know, if at the end of the day the provider doesn't believe
that fraud has occurred, in other words, they don't believe
that they have exposure liability exposure
under the fraud laws then the OIG's protocol is not the place to be.
We're here to resolve to provide a conduct -- to resolve conduct that implicates a fraud statute,
as I said, over-payments, an innocent mistake should go
through the claim's reconciliation process.
Once we receive a submission it's reviewed by a paralegal in counsel's office they review it
to see if it's complete if it's not complete you'll get a letter asking
for whatever is missing.
We also do a law enforcement check to see if the provider is under investigation by us
or another agency; this process can take a period of time so depending on the complexity
of the disclosure and the responsiveness of everyone involved.
After the matter has been accepted OIG staff will review the matter and determine how to work
with the provider to verify the information and reach a solution,
because the plan for all disclosures is to end in a settlement agreement.
Sometimes as part -- once OIG has verified the information.
We coordinate with the Department of Justice on the matter.
Sometimes DOJ requests to be involved and the matter turns
into a False Claim's Act settlement.
Other times that does not happen and the OIG enters
into a Civil Money Penalty Law settlement with the provider.
In recognition of coming forward and disclosing conduct providers are generally permitted
to pay a lower settlement amount than providers who have not self-disclosed
who are subject of affirmative investigations.
Another incentive to disclose is that the OIG has said
that we would presumably not require a corporate integrity agreement in order
to resolve a disclosure so long as the provider has fully cooperated in the disclosure process.
As I said earlier, disclosing a problem and working collaboratively with the government
to resolve it shows that your compliance program has been fully incorporated
into your organization is saying actions speak louder than words reigns especially true
in this situation that's why we believe we provide 2 valuable incentives both a lower
settlement amount as well as a presumption of no CIA in order to recognize providers
that have done the right thing and fully embraced a culture of compliance.
So that is the end of my section and the end of the second session of today.
We will take a break.
The speakers will be around for questions and we will reconvene at --
we're going to take a 5 minute break and we'll reconvene at 11:50, 11:50 okay.