‘Favorable treatment’ offered for self-disclosure
Favorable treatment’ offered for self-disclosure
Health care providers who promptly self-disclose improper conduct to the government may be eligible for "favorable treatment in the resolution of their cases," including less rigorous corporate integrity agreements, according to state- ments by Inspector General June Gibbs Brown.
"We want to encourage providers to come forward and disclose conduct that threatens the federal health care programs, including Medicare and Medicaid," Brown said in announcing an open letter from Office of Inspector General [OIG] on the topic. "A provider’s good-faith self-disclosure and continued cooperation go a long way in convincing the Office of Inspector General that less rigorous integrity requirements are needed to protect the federal programs."
Typically, all corporate integrity agreements include a provision to exclude a provider from participation in the federal health care programs if the OIG determines the provider has materially breached the terms of the agreement. Generally, that provision is necessary to ensure that the OIG maintains the ultimate remedy to protect the federal health care programs from problem providers.
Many providers entering into corporate integrity agreements have expressed concern about the exclusion remedy, Brown said. In response, the OIG may forego the exclusion remedy in appropriate self-disclosure cases where the providers demonstrate sufficient trustworthiness to allow the OIG to conclude that the federal health care programs can be safeguarded without the exclusion remedy.
The OIG’s options
Additionally, if a self-disclosing provider has demonstrated that its compliance program is effective and agrees to maintain the program as part of a False Claims Act settlement, the OIG may not even require a corporate integrity agreement. The decision on whether to impose a corporate integrity agreement is influenced by a number of variables, including the scope and seriousness of the misconduct, the risk of recurrence, whether the disclosed matter was identified and reported as a result of the provider’s compliance measures, and the degree of the provider’s cooperation during the disclosure verification process, the OIG says.
In cases where it is necessary to require the self-disclosing provider to enter into a corporate integrity agreement, the provider may need to make only limited changes to its existing policies and procedures to meet most of the requirements.
For example, when the provider’s own audits detected the disclosed problem, the OIG may consider alternatives to standard auditing requirements and permit a self-disclosing provider to perform some or all of the billing audits through internal auditors rather than through an independent review organization. Additionally, the OIG may narrow the scope and focus of the claims review to the areas found to be out of compliance or allow alternate audit methodologies in place of the statistical sampling methodology generally required.
Since 1995, the OIG has received 75 self-disclosures from providers ranging from hospitals to laboratories to physicians. The OIG has accepted 64 of the self-disclosures, and 11 of the cases have been resolved with about $36.8 million slated for collection through civil and administrative settlements or overpayment recoveries.
A pilot voluntary disclosure program was started by the OIG in 1995 as part of Operation Restore Trust, an anti-fraud initiative aimed at durable medical equipment suppliers, home health agencies, nursing homes, and hospices in California, Florida, Illinois, New York, and Texas. To be eligible, an applicant had to be a corporate entity doing business in one of the Operation Restore Trust states in one of the designated health care sectors. Few providers took advantage of the pilot program, with 20 providers making self-disclosures and 14 being accepted between May 1995 and October 1998.
In October 1998, the OIG announced a new more flexible provider self-disclosure protocol that can be used by all health care providers doing business with Medicare, Medicaid, and other federal health care programs. Since the new protocol was announced, 55 providers have self-disclosed, with 50 gaining acceptance into the program. The provider self-disclosure protocol is available on the OIG’s Web site at http://www. hhs.gov/oig/oigreg/selfdisclosure.pdf.
The self-disclosure protocol is designed only for providers who believe a potential violation of the law may have occurred. Matters exclusively involving overpayments or errors that do not indicate that violations of the law have occurred should be brought directly to the attention of the entity responsible for claims processing and payment.
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