False Claims Counsel

On April 19, Inspector General Daniel Levinson of HHS spoke at the Health Care Compliance Association Annual Compliance Institute. In an outline published on OIG-HHS’s website, Levinson identifies compliance areas he expects the recently passed healthcare reform bills to change.

In addition to the lengthier outline, the OIG-HHS released a one-page summary titled “Some Questions Compliance Professionals Should Ask As They Prepare for Health Care Reform” (click on the link to see better formatting):

Some Questions Compliance Professionals Should Ask As They Prepare for Health Care Reform
Excerpt from a keynote address delivered by Daniel R. Levinson, Inspector General for the Department of Health & Human Services, at the Health Care Compliance Association’s Annual Compliance Institute on April 19, 2010

Transparency: Are you prepared to operate in a more transparent health care system?

• Does your organization have the right systems and technologies to meet new demands to collect, organize, track, retain, and report information and data accurately and completely?
• Do you have security and privacy protections in place for creating, transmitting, and storing data?
• Do you have systems in place to meet enhanced reporting and disclosure requirements applicable to your industry segment?

Quality: Are you focused on quality as a compliance issue?

• Do your clinicians understand that quality is a compliance concern and that quality of care is increasingly integral to payment?
• Do you have systems that will ensure that charting, collection and reporting of quality data, and clinical documentation are accurate, complete, and sufficient to justify payment?
• Are you present during conversations and involved in decisions about quality in your organization?
• Does your compliance department have the expertise to address quality-related compliance issues?
• Are your board of directors and management informed about the heightened role of quality of care under health care reform?

Accountability: Is your organization prepared for greater accountability?

• Do you have a compliance plan in place? If not, is your organization prepared to create and implement one?
• Do you know with whom your organization does business?
• Does your organization have affiliations with excluded, suspended, or Medicare debt-owing individuals and entities?
• Are you prepared to meet new requirements for background and licensure checks?
• Are the persons furnishing services through your organization qualified to do so?
• Are you focused on identifying and addressing new fraud and abuse risk areas that may arise as your organization becomes involved with new payment and delivery systems (such as medical homes, accountable care organizations, bundled payments, and value-based purchasing)?
• For example, are you thinking about risk areas such as inappropriate stinting on care, “cherry picking” patients, “lemon dropping” patients, gaming of payment windows, and misreporting of quality or performance data?
• Will you have safeguards in place to address these and other risks?
• Will compliance be part of the conversation as your organization contemplates new business and reimbursement arrangements?
• Is your organization addressing its increased compliance and quality responsibilities under health care reform?
• Are managers, staff, and contractors aware of their responsibilities?
• Are your training systems robust enough to support a new learning curve?
• If you represent a private insurer or employer organization preparing to participate in new public programs (e.g., participating on the exchanges or in the temporary employer retiree reinsurance program), does your organization have systems in place to ensure compliance with applicable program requirements?
• Do you have systems in place to screen for improper claims before they are filed?
• Are you using data mining and other techniques and technologies to detect improper claims?