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New Directions in Healthcare Compliance, Identified by the OIG

April 1, 2021
April 1, 2021

In the world of healthcare compliance, the HHS Office of Inspector General OIG plays an important and determinative role. HHS OIG is the largest inspector general's office in the Federal Government, with approximately 1,600 dedicated to combating fraud, waste and abuse and to improving the efficiency of HHS programs. A majority of OIG's resources goes toward the government oversight of Medicare and Medicaid—programs that represent a significant part of the Federal budget and that affect this country's most vulnerable citizens. OIG's oversight extends to programs under other HHS institutions, including the Centers for Disease Control and Prevention, National Institutes of Health, and the Food and Drug Administration.

In our efforts to identify new compliance directions, content experts from HCCS, A HealthStream Company, recently attended the Health Care Compliance Association’s 2018 Enforcement Conference. We’ve already blogged here about the first round of things they learned. Here is an excerpt from Round 2:

Session Title: OIG Administrative Enforcement Update

This was another great OIG session packed with information on the Fraud Risk Indicators, exclusion, the civil monetary penalties law (CMPL), and employing excluded individuals. This section will focus on the CMPL. The OIG uses the CMPL for enforcement actions on false or fraudulent claims, arranging or contracting with an excluded person, ordering or prescribing while excluded, patient dumping, grant fraud, etc. A person or entity knows that they are under investigation when the OIG makes contact. If the OIG has made contact, they probably have evidence such as claims data to make this determination.

The OIG’s forensic data analysis uses data mining—the process of sorting through large amounts of data and extracting previously unknown information—to identify aberrant billing trends that would otherwise remain hidden. It allows for a flexible approach to fraud detection, uses a larger data warehouse, identifies a wide range of trends, and provides quicker results based on near real-time data. The tool identifies abnormalities, patterns and trends of abuse, cost-saving areas, and allows for the assessment of quality of care. The data is reviewed for outliers. The OIG starts with the assumption of fraud when they find an outlier.

Current enforcement trends identified by the OIG include the following:

  • Quality of care
  • Opioids
  • Individual accountability - Yates memo
  • Kickbacks
  • EMTALA
  • Diagnostic providers
  • Employment of excluded individuals
  • Grants and contracts
  • Hospital billing
  • Managed care
  • Home health

One of the many examples shared based on outliers was about an OB/GYN in New Jersey who ranked third in volume in that state for billing physical therapy (PT). In addition to billing for procedures outside of the scope of gynecology, there were a number of other allegations such as billing for services while he was travelling and billing for PT provided by unqualified persons. He ended up with a 20-year exclusion.

Whether the focus is on post-acute or the continuum of care, criminal health care fraud, state privacy laws or OIG administrative enforcement, there are many agencies, in both the public and private sectors, working to combat health care fraud, waste, and abuse. All organizations are subject to increased scrutiny. Based on the guidance from all the experts at this conference, maintaining a high level of diligence is the best way to keep an organization out of trouble.

Download the article that summarizes learning from this HCCA Conference.