OIG is looking for input for managed care model
OIG is looking for input for managed care model
OIG is soliciting input on what should go into its model compliance plan for managed care. More specifically, it wants input regarding Medicare+Choice organizations that offer coordinated care plans. Coordinated care plans, as defined by HCFA, comprise networks of providers that deliver benefits to an organization. These networks include HMOs, PPOs, PSOs, religious and fraternal benefit plans, and most other network plans. HCFA already mandates that Medicare+Choice groups have a compliance plan.
OIG's request reflects the agency's new policy of seeking industry guidance on model compliance plans, in contrast to past efforts where OIG devised the plan itself. That drew fire from providers who felt shut out. Now they have until Nov. 23 to submit their comments.
Nonetheless, managed care is likely to be the odd bird in OIG's flock of model plans, which have already been issued for labs, hospitals, and home health agencies. While the other plans focused on stopping overbilling, managed care compliance will most likely target denial of care as well as quality of care. Some federal prosecutors, such as Jim Sheehan in Philadelphia, argue that capitated plans that skimp on care are as equally guilty of fraud as fee-for-service providers who upcode.
Note that OIG does not want anyone to send a comprehensive compliance plan for the agency to look over. Instead OIG wants concise hints that specifically address what compliance risk areas exist for managed care groups, as well as how these groups can fit into the agency's seven-plank framework for a comprehensive compliance program. The seven points include: creating written policies; appointing a compliance officer and board; training employees in compliance; creating lines of communication such as hotlines; enforcing compliance standards; monitoring compliance through audits; and procedures to investigate and correct violations.
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