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November 29, 2012

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A Return to  Compliance: What's at Stake in the Future?

W ith President Obama in office for a second term and his administration under pressure to move forward with healthcare reform and to show ongoing progress in its fraud prevention initiatives . . . your medical practice, hospital, or other healthcare organization is likely to experience added scrutiny in the coming years.  The CMS Fraud Prevention System in cooperation with OIG and other federal agencies has steadily increased fraud detection and prosecution since the passage of the ACA.  They’ve recovered some $10.7 billion in fraudulent claims since 2008, expect to recover an additional $6.9 billion in FY 2012, and have pledged to do even more in the future.

What does this have to do with you?  . . . It’s all about the Data.

Like just about every other aspect of healthcare in the 21st Century . . . one of the keys to moving forward with fraud detection involves new ways to use data.  Besides traditional fraud detection and enforcement procedures, the new Fraud Detection System screens data from all claims and using a “predictive analytic technology,” detects which claims have “aberrant and suspicious” billing patterns that warrant further scrutiny.

This doesn’t really have anything to do with you or your organization, does it?  You have an effective Compliance Plan in place.  You are certain no one in your organization is involved in any activities (common examples include incorrect, inaccurate, or up-coding, taking gifts from vendors, ordering medically unnecessary procedures) that would draw the attention of CMS, OIG, DOJ, HHS . . .  and certainly not HEAT (the interagency “Medicare Strike Force”), right?

Avoiding scrutiny in the future will have much more to do with how your organization collects, manages, and controls Medicare and Medicaid claims data . . .  and the position your organization takes toward meeting the requirements.   And even if you are unaware, if there’s a bad actor in your organization and you should have known, you may still be personally and criminally liable.

Compliance for the Right Reasons.
You can choose to resist these changes and do the minimum necessary to avoid legal trouble.  When your organization hangs back and does the minimum to comply with (or ignores) healthcare compliance requirements, you put yourself in an increasingly vulnerable position and are much more likely to fall under regulatory scrutiny.

You can also recognize that there’s a higher calling here, take needed steps to prepare for the new requirements, and even give your organization a competitive advantage in the long run through increased efficiencies and a renewed focus on quality.   When you are the driver of efficiency in your organization, you are in a better position to insulate your organization from regulatory risk and to reap the benefits of “doing the right thing.”

Proactive steps you can take to insulate your organization from OIG scrutiny. 

• Develop an “effective” plan (you can seek outside help from a consultant, but the final plan has to be yours and be proven effective within your organization).

• Learn more about the specific risks to your organization and the steps you and others in your organization should take starting in 2013. 

• Be aware of what’s at stake if you choose to ignore the reality of what can go wrong with healthcare compliance . . . Here’s our Directory of Laws that together form the teeth of healthcare compliance . . .

• The Health Insurance Portability and Accountability Act (HIPAA). Every time you submit an electronic claim or create an EHR, this law comes into effect.

• False Claims Act (31 USC§3729). If someone in your organization submits an inaccurate or false claim, you risk violating the False Claims Act.

• The Anti-Kickback Statute (42 USC§1320a). If anyone in your organization asked for, offered, gave or received anything of value to or from a vendor connected with Medicare services, you could be in violation of this law.

• The physician self-referral (“Stark Act”) law (42 USC§1395). If a physician in your organization refers a Medicare patient to a provider that he or she has a financial interest in, you may be in violation of this law. 
   

  . . . PBN is here to help. If you have compliance questions or needs, contact PBN Business Development, 800.288.4901 or .

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Overland Park, KS 66210 | 800.288.4901 | pbnmed.com

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