OIG 2013 Work Plan – Hospital Issues Aded To OIG Work Plan

Hospitals—Inpatient Billing for Medicare Beneficiaries (New)

Hospitals—Diagnosis Related Group Window (New)

Hospitals—Non-Hospital-Owned Physician Practices Using Provider-Based Status (New)

Hospitals—Compliance With Medicare’s Transfer Policy (New)

Hospitals—Payments for Discharges to Swing Beds in Other Hospitals (New)

Hospitals—Payments for Canceled Surgical Procedures (New)

Hospitals—Payments for Mechanical Ventilation (New)

Hospitals—Quality Improvement Organizations’ Work With Hospitals (New)

Hospitals—Acquisitions of Ambulatory Surgical Centers: Impact on Medicare Spending (New)

Critical Access Hospitals—Payments for Swing-Bed Services (New)

Long -Term-Care Hospitals—Payments for Interrupted Stays (New)

Issues That Continue To Be On OIG Radar

Hospitals—Same-Day  Readmissions

Hospitals—Acute-Care Inpatient Transfers to Inpatient Hospice Care

Hospitals—Admissions With Conditions Coded Present on Admission

Hospitals—Inpatient and Outpatient Payments to Acute Care Hospitals

Hospitals—Inpatient Outlier Payments: Trends and Hospital Characteristics

Hospitals—Reconciliations of Outlier Payments

Hospitals—Duplicate Graduate Medical Education Payments

Hospitals—Occupational-Mix Data Used To Calculate Inpatient Hospital Wage Indexes

Hospitals—Inpatient and Outpatient Hospital Claims for the Replacement of Medical Devices

Hospitals—Outpatient Dental Claims

Hospitals—Outpatient Observation Services During Outpatient Visits

Critical Access Hospitals— Variations in Size, Services, and Distance From Other Hospitals

Inpatient Rehabilitation Facilities—Transmission of Patient Assessment Instruments

Inpatient Rehabilitation Facilities—Appropriateness of Admissions and Level of Therapy

Customization and Scalability of Compliance Programs

Creating a Compliance Program That is Right for Your Organization

An important part of developing an effective compliance program is to make the program scalable and effective for the operations of the specific provider.  In some ways, creating compliance program for a large health system is the easiest because you have the resources and breadth of operations to recommend everything; also known as the “kitchen sink” model.  The real art in my opinion comes when developing programs for smaller hospitals, physician groups and other organizations that do not have the resources to “do it all.”  Taking an overbroad approach to compliance with smaller organizations can actually create additional risk because you are creating a “roadmap” of items that are not being done and which you will never have the resources to complete.

Our job as compliance attorneys is to recommend systems that are workable within the resources and specific risk areas that are relevant to the provider.  This takes a level of judgment that is not necessary where the size and resources of the organization permit the “kitchen sink” approach to be taken.

The development of compliance programs for smaller organizations take a surgical approach.  Care must be taken to develop systems for identifying the risk areas that are specific to the organization.  Risks should be scored and prioritized and the results of this process should be included into a plan to accomplish audits, reviews or monitoring of the various identified risk areas.  Small organizations cannot hit every risk area during every budgeting cycle.  A longer term approach is called for with the most urgent risks requiring closer and faster review.  This all ties into the budgeting process.  The work plan needs to be adequately budgeted.  The size of the organization will have an effect on the amount that is budgeted for compliance.

The point of a compliance program is not that every problem area will be found.  It is most important that a logical system be developed that prioritizes risk and addresses risk areas in a logical fashion.  The other side of the coin is that a substantial organization should not hide behind lack of resources for not addressing significant risk areas.  A small physician practice is at one end of the spectrum.  A hospital system with several facilities, attached physician network, and an array of ancillary services would have little excuse for not allocating sufficient budget amounts to compliance to enable the organization to meet its compliance needs.

Issues of scalability also come into the general structure of the compliance program.  A small physician practice will not have the resources to hire a chief compliance officer.  Rather, a small practice might designate a partner or administrator as a “compliance responsible individual.”  On the other hand, a substantial hospital system should implement a robust structure including a full-time chief compliance officer, a compliance committee and compliance staff.  The compliance officer should not serve a dual role in positions that create an inherent conflict of interest such as general counsel, chief financial officer or chief operating officer.

Issues of scope and scalability are at the center of most compliance efforts.  These issues require careful and judiciously made decisions.  These decisions are important and must be faced by providers of all size, from the smallest medical practice through the largest health system as mandatory affective compliance programs become a requirement.

Physician Compensation – A Look In Time At The Covenant Healthcare

Waterloo, Iowa.  Population 70,000 (give or take).  Who would expect that this town would be the focal point of one of the biggest physician compensation/Stark Law settlements in history.

In 2009, Covenant Medical Center in Waterloo agreed to pay the Federal government $4.5 million to settle charges that it had overpaid five doctors.  The Stark Law is violated if a physician is paid in excess of fair market value for services or if the compensation is not commercially reasonable.

The Affordable Care Act made it clear that Stark Law violations can trigger liability under the Federal False Claims Act.  The result is that amounts that are billed under the “cloud” of Stark can lead to treble damages plus up to $11,000 per claim.  If the Stark Law violation involves payment in excess of fair market value to a physician, the basis for assessing damages can be three times the amount of the physician’s billing plus up to $11,000 for each claim.  The application of the False Claims Act to Stark Law violations has placed a renewed focus on physician compensation issues.

In the Covenant care, the government alleged that the five physicians were paid commercially unreasonable compensation, far in excess of fair market value.  The hospital denied any wrongdoing but paid the government $4.5 million plus interest to settle the claims.

 Physician compensation has become a more sensitive issue than it ever was in the past.  The Waterloo, Iowa case demonstrates that smaller towns are not immune from the impact of the Stark Law and False Claims Act.

OIG Fraud and Abuse / HEAT Program Videos

The Office of Inspector General is posting a series of video presentation on the HEAT program.  Topics covered include general information on health care fraud laws, the Anti-kickback Statute, the False Claims Act and dealing with investigations.  The OIG will be posting a total of 11 videos and audio podcasts that are part of the award-winning Health Care Fraud Prevention and Enforcement Action Team (HEAT) Provider Compliance Training initiative. The first educational presentation was posted on the OIG website the week of December 5.  New posting will be made over the next few months.

As of the time of this post, the OIG page includes 4 new videos.  One is an introduction to the new video program.  Other current videos cover the False Claims Act, Anti-kickback Statute and Program Exclusions.

You can access the OIG video web site here:  OIG Fraud and Abuse Videos

Through the OIG video presentation page, you can also access a series of 16 videos covering a variety of compliance related topics including: