The good thing about compliance is that there is always a roadmap to rely upon and guidance from the enforcement authorities on where to focus your compliance efforts.
The “go-to” document issued each year is the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan. The OIG released its 2017 Work Plan in November, and there is a lot that can be learned by reviewing it. We’ve captured a few highlights below.
First, in 2017 the OIG will focus on studying and prosecuting fraud and abuse. In particular, it will bolster HHS and National Institutes of Health (NIH) data security measures, review the Food and Drug Administration’s (FDA’s) plan to address cybersecurity issues regarding medical devices, and tackle electronic health record (EHR) challenges facing providers today. Also, the OIG plans to audit HHS information security system controls that track prescription drug reimbursements. The Work Plan outlines several other new and ongoing initiatives and projects within HHS as well.
The OIG is concerned with the Government Accountability Office (GAO) findings on improper incentive payments, and the OIG will access Centers for Medicare & Medicaid Services (CMS) safeguards to prevent invalid meaningful use payments.
Finally, in 2016 the OIG excluded an additional 3,635 individuals and entities from participation in federal healthcare programs. This raised the total number above 60,000 for the first time.
Proposed Exclusion Expansion Authority
The OIG has submitted its proposed increase in exclusion authority to close a gap that currently exists. The gap prevents OIG from issuing an exclusion for an office of a managing employee unless the person is currently employed at the company that has been penalized for fraud. So if such a person leaves that company, the OIG is not permitted to exclude them for prior actions.
Increased Fines and Penalties
The Federal Civil Penalties Inflation Adjustment Act of 2015 took effect Aug. 1, 2016, and increased fines for inflation.
(Life) Billing after Death
The OIG is also focused on a pervasive problem with regard to providers that bill for services after an individual’s death. There are four studies the OIG is undertaking in 2017 to address this problem, including those focused on:
- Medicare payments for service dates after individuals’ date of death – as required under Section 502 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), no payments can be made by CMS for services after the death of the patient. The OIG will review CMS policies and procedures to ensure that these do not continue.
- Medicare Part C payments. In 2011, $20 million was paid for Part C services to deceased individuals after their death. Federal regulations require the MA organization's disenrollment of a beneficiary from its plan upon the death of the individual, effective the first day of the calendar month following the month of death.
- Same for Part D payments.
- Same for MCO payments.
Civil Fines and Penalties for Skilled Nursing Facilities
Effective Sept. 6, 2016, such fines more than doubled. For example, the OIG raised the maximum penalty for noncompliance from $10,000 per day to $20,628 per day. In addition, new fines were implemented for situations in which an individual notifies the SNF of impending survey prior to its occurrence, for improper billing and/or for instances for failing to meet certification requirements.
From the introduction of the OIG Work Plan to the presidential election, one thing is for sure: significant change is likely to happen in healthcare. However, when it comes to compliance, logic would tell you that there are certain measures within the Patient Protection and Affordable Care Act (PPACA) that speak to this. One of those has its origins dating back to the early 1990s.
As it pertains to exclusion monitoring, the OIG recommends performing it in its guidance, and it has and will continue (despite any rewrite of the PPACA) to enforce civil fines and monetary penalties for hiring, billing, or contracting with an excluded person or entity. That is one piece of compliance that will remain in place.
To learn more, go online to https://oig.hhs.gov/reports-and-publications/archives/workplan/2017/HHS%20OIG%20Work%20Plan%202017.pdf.https://oig.hhs.gov/reports-and-publications/archives/workplan/2017/HHS OIG Work Plan 2017.pdf