BlickenWolf has extensive experience as an Independent Review Organization (IRO) helping healthcare organizations in meeting Office of the Inspector General (OIG) compliance obligations in the settlement of federal healthcare program investigations.
Our
team brings a unique understanding of how the government approaches issues combined
with how healthcare delivery really works to assist clients in
meeting the Corporate Integrity Agreement (CIA) obligations.
The Office of Inspector General has entered into Corporate Integrity Agreements,
(CIA), with various types of healthcare providers, pharmaceutical manufacturers,
and payers. In addition, several States have also adopted CIA-type agreements
when settling certain fraud-related matters with providers. Over the last several
years, the language in these agreements has become standardized to the point
that the activities required of the Independent Review Organization (IRO) have
been categorized into four types of engagements. The IRO is required to perform
certain review/audit related procedures and develop a written report which
is submitted with the company’s Annual Report to the OIG. CIAs vary in length
from one to seven years. A company that enters into a CIA may be required to
have one, some, or all of the following types of engagements performed:
- Compliance – performed as an “agreed-upon procedures”
engagement as defined in the AICPA’s Statement of Position (SOP
99-1). Requires the IRO to develop review procedures to assess
the company’s compliance with certain CIA requirements including
but not limited to activities involving the seven fundamental steps
that are to be included in all compliance programs.
- Billing - requires the IRO to select and review
a sample of medical and billing records usually particular to the
type of services which triggered the settlement with the OIG.
- Systems Review - usually performed secondary
to the Billing Engagement should the error rate found be greater
than five percent. This requires that the IRO document the policies/procedures
and controls in place throughout the revenue cycle associated with
the types of services reviewed to identify why the errors occurred,
weaknesses in controls, and recommendations for improvement.
- Unallowable Cost Review - hospital providers submit Cost Reports to their fiscal intermediaries. Certain costs associated with the hospital’s settlement are not to be claimed on the cost report and are thus categorized as unallowable costs. The IRO is required to analyze the hospital’s costs associated with the settlement and agreement to assure the OIG that the hospital did not inappropriately claim costs it should not have.
