Updated on: June 22, 2012

Live from Las Vegas: Make “Reasonable” Efforts to Comply, says HHS Inspector General

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Original story posted on: April 30, 2012

"The OIG isn't another acronym in Washington," opined Daniel Levinson, Inspector General of the Department of Health & Human Services (HHS) Office of Inspector General (OIG), during his interview with Kim Charland, senior vice president of consulting for Panacea Healthcare Solutions, on today's Monitor Monday, broadcasting live from the HCCA Compliance Institute in Las Vegas.

 

It is, he said, an office of people who are working in tandem with the healthcare community to protect taxpayer dollars, act in the best interests of the Medicare and Medicaid programs, and ensure compliance with the law. The bottom line, as far as Levinson goes, is this: "Reasonableness is the cornerstone of what compliance should be about."

 

The topic of "reasonable" also surfaced during an interview with another key player in the federal government: Ketanji Brown Jackson, vice chair and commissioner of the U.S. Sentencing Commission-an independent agency in the federal government's judicial branch. Jackson briefly discussed the 2010 revisions to the U.S. sentencing guidelines and their application to healthcare compliance and ethics programs.

 

Inside the OIG

 

In addition to being one of the most widely recognized acronyms in the healthcare industry-and sometimes one of the most feared, the OIG is the oversight and enforcement arm of all parts of HHS, which includes the likes of such agencies as the Centers for Medicare & Medicaid Services, Food & Drug Administration, Centers for Disease Control & Prevention, National Institutes of Health, and others.

 

Most of the OIG's staff consists of auditors, evaluators, and criminal investigators, and their tasks are in line with their titles. Specifically, auditors conduct audits for money, evaluators evaluate for the effectiveness of the Medicare and Medicaid programs, and criminal investigators investigate potential fraud. These activities form the core of the OIG's mission, Levinson says, and by law 80 percent of its resources focus on the Medicare and Medicaid programs.

 

Levinson reports that his office's most publicized work is its participation in the Medicare Fraud Strike Force-a joint effort between the HHS and the Department of Justice. This multi-agency team of federal, state, and local investigators is designed to combat Medicare fraud through the use of Medicare data-analysis techniques and an increased focus on community-policing operations.

 

"We have brought back billions of dollars as a result of shutting down healthcare scams of all varieties" in all states across the county, says Levinson. "We have a lot to show for our work."

 

Levinson also said that many staff members are "busy in outreach-information and education efforts." During the last year or so, the OIG has launched a variety of new services on its website, including podcasts, educational videos, and other compliance-related material. All of these resources are now on its website at http://oig.hhs.gov/, and, as he said, "Compliance officers and their staff can take advantage of the guidance without leaving their offices." He also encourages providers to keep the conversation going by using social media outlets such as Twitter and email list serves.

 

Although Levinson did not reveal any secrets about the OIG's future focuses, he did say that, in general, "Healthcare delivery will be different than it is now, and it will include coordinated care and global payments." Toward those ends, OIG staff members are currently consulting with CMS about various new vehicles, specifically accountable care organizations (otherwise known as ACOs) and the Medicare shared savings program.

 

Another Avenue for Compliance

 

The Commission revised the federal sentencing guidelines in 2010 to address several concerns. For example, as Jackson said, they clarified that a corporation must take "reasonable steps" to respond appropriately and to prevent criminal action in the future. "Reasonable" refers, for example, to self-reporting, assessment and modification, and identification of the guilty party.

 

Speaking about the importance of establishing effective compliance programs, Jackson indicated an organization faces fines if it is found to be in noncompliance, but those fines can be reduced if it can prove that it took good-faith efforts to follow the law, which includes having a good compliance program. As she said, "A compliance program demonstrates the position of company toward law-breaking" and shows that the topic was addressed before the crisis occurred.

 

For example, Jackson says, "A periodic review must be conducted to ensure effectiveness." In addition, it's important to remember that a "compliance program isn't a static entity" and must be evaluated an ongoing basis. For example, when certain federal regulations change, healthcare organizations may need to change the guidance in their compliance program. In addition, she says, "A company also may change, grow or shrink. In conducting a review, an organizational approach should be tailored to its specific size and the reality of the organization."

 

The sentencing guidelines put significant responsibility on high-level officers, someone from the organization's governing board. "Section 8B2.1 [of the guidelines] requires that the organization's governing authority must be knowledgeable about the content and operation of the program and exercises oversight over the program." The governing authority also must be involved with the compliance program's implementation and effectiveness.

 

In her wrap-up, Jackson encourages providers to submit comments on the recent changes and priorities. For more on the USC and its guidelines, see www.usc.gov.

 

About the Author

 

Janis Oppelt is the editorial director for MedLearn Publishing, a Panacea Healthcare Solutions company, St. Paul, MN.

 

Contact the Author

 

joppelt@medlearn.com

 

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