Admitting errors gives you the ‘moral high ground’
Admitting errors gives you the moral high ground’
Reveal compliance problems voluntarily
When it comes to potential compliance problems, it’s critical that you conduct an internal investigation before the government forces you to do so, advises Michael Kendall, a partner with McDermott, Will & Emery, in Boston.
The payoff is that knowing just how big a possible compliance problem you have can give you the advantage of self-disclosing to the government before investigators target you for a formal investigation.
"It’s always best if you are first in the door — if you knock on their door before they knock on yours," said Kendall. "It gives you a certain moral high ground." Self-disclosure can also give your dealings with your Medicare contractor or fiscal intermediary a boost should there be any future questions about your reimbursement patterns.
"Your credibility is a valuable asset that should be protected," agrees James Bryant, Program Integrity Branch Chief with the Health Care Financing Administration.
Here are six rules Kendall says are essential to properly conducting an internal investigation before the government arrives:
1. Be the first to gather all the facts. Interview witnesses, read documents, and go to the suspected site of wrongdoing to understand how the process in question works.
2. Discover all legal problems before the government does. A sure grasp of the situation will help you form your defense.
3. Fully analyze applicable law. A large part of most cases involves educating the prosecutors about the particulars of your situation, so make sure you know how it and the law come together.
4. Stop all violations before the government does. When you learn of a potential problem stop it — immediately.
5. Tell the government. It is best to take advantage of the self-disclosure protocols put out by the Office of the Inspector General when you find something is amiss — especially if it is something the government is likely to discover on its own.
6. Don’t obstruct justice. Do not alter or destroy any documents. "It’s probably best to also stop any routine destruction of documents. Plus, make sure to instruct your employees to tell the truth if they are interviewed by the government," he advises.
Should you get hit with an allegation by a Medicare carrier that you were overpaid or had other billing errors, and decide to challenge, here’s a short guide from the American Medical Association about how the appeals process works:
• First step. Physicians are often given the opportunity to make their case to the carrier before an audit becomes final. Once the audit is complete, physicians must return any overpayments within 30 days. Payments can be spread out over a period of time if the physician can prove financial hardship.
• Fair hearing. This appeal level gives physicians and their representatives a chance to dispute audit findings before a hearing officer, who is typically someone working for the carrier. The hearing can be held over the telephone or conducted via written correspondence. Most lawyers and consultants recommend that physicians opt for a face-to-face meeting. Government guidelines state that a carrier must hold a fair hearing and issue a decision within 120 days of a physician’s request for an appeal.
• Administrative law judge. Physicians can appeal a hearing officer’s decision to an administrative law judge if the disputed amount is at least $500. They have 60 days from the date of the decision to make their appeal request. Administrative law judges work for the Social Security Administration and typically receive special training in Medicare Part B appeals. Hearings do not have to be scheduled within a set time frame, nor must the judges issue their decision within a set period after the hearing is held.
• Medicare Appeals Council. Physicians can take their dispute to the council by requesting an appeal within 60 days of receiving an administrative law judge’s decision. The council can also initiate its own review of a judge’s decision. The law does not set any deadlines for either holding hearings or issuing decisions.
• Federal court. Once all other options are exhausted, physicians can file a lawsuit in federal court.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.