Medicare fraud and abuse investigations are on the rise, with SimiTree compliance and regulatory team reporting increased numbers of payment related audits and investigations, and saying they expect more to come.
A recent work order released by the Office of Inspector General (OIG) called for increased Medicare scrutiny. News headlines throughout the summer reflected the OIG’s intensifying focus on compliance for all healthcare providers, including home health and hospice.
In August, more than a dozen leaders at Novus Health, a large Dallas based hospice provider, were sentenced to a combined 84 years in federal prison for defrauding Medicare.
The best protection against increasing Medicare audits and investigations is a proactive approach, with full compliance assessments to identify risks and vulnerabilities, according to Kim Skehan, SimiTree Director of Compliance, Regulatory and Quality.
She also recommends keeping a watchful eye on recent Corporate Integrity Agreements and OIG Work Plans, which offer providers some insight about home health OIG compliance expectations for a compliance program.
A Corporate Integrity Agreement (CIA) is a binding agreement between the OIG and a healthcare provider which has been investigated and found guilty of Medicare fraud or abuse.
"CIAs are often part of a civil settlement involving a corporate health care provider, the OIG, or the Department of Justice," Skehan said. "The settlement may also involve state government, as in cases involving Medicaid."
In exchange for the agreement, the OIG allows the entity to continue participating in federal healthcare programs, Skehan said.
The CIA typically lasts for 5 years and holds the healthcare provider accountable for addressing areas of noncompliance, ensuring proper compliance program oversight, establishing written standards and policies, and monitoring and reporting compliance efforts and activities.
Governing boards, too
"Recent CIAs tell us the OIG is taking compliance very seriously, with CIAs consistently reflecting the expectation that organizations will have in place an effective compliance officer, or in some cases more than one compliance officer, fully trained,” Skehan said.
But compliance isn’t just for compliance officers.
Skehan noted that the OIG expects compliance to be a top to bottom organizational effort, with members of the governing board held accountable for oversight.
"In some cases, Corporate Integrity Agreements have also required members of the organization’s governing board to receive training in corporate government responsibilities for review and oversight of the compliance program,” Skehan said.
SimiTree has extensive experience in reviewing CIAs and working with healthcare entities trying to implement them.
SimiTree is approved by the OIG to serve as an Independent Review Organization which monitors a contracted entity’s efforts to fulfill its CIA.
Skehan leads the SimiTree compliance and regulatory team with the specialized knowledge and expertise required to provide expert reviews and audits required as part of the process.
"An IRO is an essential component of a CIA executed with a healthcare organization as part of a civil settlement,” Skehan said. "The CIA requires the healthcare organization to engage experts to review and audit the areas of noncompliance.”
SimiTree experts conduct all IRO audits, claims reviews, verification reviews, policies and procedures evaluations or quality monitoring that is needed to fulfill the terms of CIAs, making sure the arrangement also complies with the Anti-Kickback Statute, the Stark Law and all other federal regulations, standards, and requirements.
What CIAs tell us
The takeaway from recent CIAs, Skehan said, is that compliance should be a priority throughout the organization, from governing board members to frontline staff.
Organizations also need to make certain they are adhering to seven fundamental elements of compliance identified by the OIG, Skehan said. CIAs consistently direct healthcare organizations to meet seven basic requirements for an effective compliance program. Read details about the 7 Elements of Compliance here.
SimiTree can help
SimiTree offers full compliance assessments designed to identify vulnerabilities and show organizations where they need to provide training to mitigate risk. Our compliance team is made up of industry experts with experience across the healthcare spectrum and extensive regulatory expertise. We work with organizations to establish more effective compliance processes and assist with all other compliance needs.
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