March 2006 – Heightened Healthcare Law Enforcement Evident in Deficit Reduction Act, PEPPER Efforts, and OIG’s Exclusion of South Beach From Federal Programs; Proactive Compliance Among Healthcare Organizations Well Received
In the last decade, healthcare enforcement and compliance has experienced incredible momentum in the United States. Government continues to allocate millions of federal dollars toward enforcement and prosecution. Such efforts have been working in the fight against healthcare fraud and abuse. The number of healthcare entities and individuals who negotiated corporate integrity agreements and settlement agreements with integrity provisions reached an all time high in 2005. Over the last five years, the growth in such enforcement has been 189%. Plus, criminal convictions for healthcare fraud increased more than fourfold.
This February, President Bush signed the Deficit Reduction Act of 2005 into law. The Act impacts Medicare and Medicaid payment provisions and dedicates millions of dollars toward fraud investigation and enforcement and requires all healthcare entities receiving at least $5 million in Medicaid payments per year to establish a fraud and abuse training program by January 1, 2007. This is the first time a law has required action from healthcare entities, making compliance enforcement even broader and more targeted.
In addition to this, Medicare and Medicaid law enforcement officers have access to and are reviewing the Program for Evaluating Payment Patterns Electronic Report (PEPPER) related data available to hospitals to potentially identify inappropriate case management decisions and coding/billing issues.
Even as law enforcement has stepped up efforts, healthcare organizations are also becoming more proactive regarding compliance. BlickenWolf expects to see a growing gap between those healthcare organizations that comply and cooperate with government and those who chose to snub the government and, consequently, pay the price.
The Office of Inspector General (OIG) recently excluded Miami’s South Beach Community Hospital from participation in Medicare, Medicaid, and all other federal healthcare programs due to the hospital’s material breach of the terms of a corporate integrity agreement negotiated in 2002. Though the OIG has excluded other healthcare organizations from federal programs in the past, the promotion of its announcement regarding South Beach was very public—perhaps as a message to all healthcare organizations that the OIG is no longer going to tolerate such behavior.
What Should Healthcare Organizations Do:
- Review the OIG Work Plan
- Seek out best practices in compliance areas
- Use tools such as PEPPER to identify areas of potential errors
- Conduct regular compliance audits
- Should wrong-doing be suspected, conduct an immediate healthcare forensics investigation to pinpoint potential error
- Implement changes to eliminate errors and continue to monitor and audit risk area trends
- Provide ongoing training to staff and physicians
- If approached by the OIG, be cooperative in working through areas out of compliance
