Compliance Programs Come Center Stage As Government Tools Expand
Health Care Compliance and Our Compliance Practice
John Fisher, CHC
The current health care regulatory environment presents a high degree of risk to even the most well-intentioned provider. Recent legal changes have made it even easier for the government to pursue what they believe to be improper activities. The government is taking a “return on investment” approach to pursuing health care fraud and is coming out on the winning end of this game. Reports state that the government collects approximately $15 for every $1 that they invest policing health care fraud. In addition, Whistleblowers continue to bring a steady flow of cases against health care providers. Even though there is a dispute over certain aspects of health care reform, the area where all ranges of the political spectrum appear to agree is on pursuing health care fraud. Therefore, we cannot expect this climate of enforcement against health care providers to go away anytime soon.
While the government continues with its “pay and chase” approach to health care fraud and overpayments, it is also integrating even more drastic measures into its bag of tools. The government is now authorized to discontinue making payments to a provider altogether upon receiving any “credible allegation” of misconduct. The allegation does not need to be proven to be true and there is not even a formal procedure to permit the provider to make its case. Yet, the financial consequences of suspending payment can be devastating.
Chances are very good that an individual provider will eventually have dealings with the government over some overpayment or fraud and abuse issue. If you have not had to deal with an investigation, you are very fortunate. Even the best intentioned providers will more likely than not need to deal with government scrutiny. When that occurs, it serves the provider well to have an appropriately scaled compliance program that is being actively worked to identify risk areas, billing mistakes, and other possible difficulties. Having an effective compliance program in place is the best way to turn the problem into something that is manageable, and turn it away from an enforcement action that can have grave consequences on operations and financial viability.
At Ruder Ware, we have assembled a multidisciplinary team of attorneys to assist providers in compliance matters. Our compliance team is lead by John H. Fisher, III, who is a seasoned health care attorney and is certified in health care compliance. Our compliance team can assist providers through the process of structuring an appropriately scaled compliance program, reviewing existing compliance program for effectiveness, and assisting with ongoing operational issues related to compliance programs.
Our compliance team brings a depth of experience in the wide range of compliance issues that affect various types of providers, such as the Federal False Claims Act, the Stark Law, Anti-Kickback Statute, Civil Monetary Penalties laws, and various legal and billing issues that pertain to the specific practice or provider. We can suggest practical approaches for identifying specific risk areas and crafting plans to minimize risks in those areas.
We are able to work with compliance departments to fashion methods for handling issues that arise through their compliance reporting systems, including the creation of corrective action plans. We advise providers regarding identification, repayment of overpayments, and where necessary, self-disclosure of legal violations to the appropriate governmental agencies using self-disclosure protocols.
When compliance problems are identified, it is critical that providers take appropriate actions to make repayment, appropriately investigate, and craft a proper resolution that avoids reoccurring or deeper difficulties. We are able to assist with these matters under the attorney-client privilege to determine the nature and scope of any discovered compliance concern. We can direct investigations and take necessary steps to remedy the problem, all while maintaining client confidentiality.
As with any other legal issue, prevention is the best medicine. Although we are equipped to assist providers as difficulties arise, we prefer to assist providers to ensure that their compliance programs are effective and appropriately tailored to the size and nature of their particular business. Ruder Ware’s compliance team has experience conducting compliance effectiveness review and “gap analysis.” This process involves in-depth due diligence review of matters relative to your compliance program, an assessment of the program, and specific recommendations aimed at making the compliance program more effective.
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Tags: compliance attorney, Compliance Program, Fraud and Abuse, physician compliance