MD - Health Care Compliance Association

defendants. Further, during this same period, a
total of 459 defendants were convicted for
health care fraud related crimes. In 2004, the
DOJ also pursued 868 new civil health care
fraud investigations and filed complaints or
intervened in 269 civil health care cases.
By Sidney Summers Welch and Sara Kay Wheeler
Editor’s note: Ms. Sidney Summers
Welch and Ms. Sara Kay Wheeler are
partners in the Atlanta office of Powell
Goldstein LLP where they focus their
practices exclusively in the area of health
law. Ms. Welch may be reached by telephone
at 404/572-6754 or by e-mail at
swelch@pogolaw.com. Ms. Wheeler may
be reached a by telephone at 404/572-
6905 or by e-mail at swheeler@pogolaw.com.
The authors would like to
thank Kinshasa K. Williams for her
assistance in preparing this article. Ms.
Williams is an associate in the office of
Powell Goldstein LLP, where she practices
in the firm’s Health Care Group.
On November 16, 2005, the United
States Department of Health and
Human Services (HHS), Office of
Inspector General (OIG), published its Fiscal
Year 2006 Work Plan. 1 The primary purpose
of the Work Plan is to articulate to the
provider and supplier community the areas of
highest risk in the programs and activities
administered by HHS and to provide a road
map of areas in which providers can expect
the OIG to pursue enforcement activities.
With the staggering financial recoveries
achieved by the U.S. Department of Justice
(DOJ) and HHS in recent years, health care
organizations transacting business with the
federal health care programs should review
this publication to identify any vulnerabilities
that may pertain to their operations. In combination
with the OIG’s series of Compliance
Program Guidance (CPGs) for various industry
sectors, such as hospitals, physicians, and
pharmaceutical companies, 2 compliance officers
should view the Work Plan as an annual
guide for updating and for effectively focusing
to update and their organization’s internal
compliance efforts, particularly auditing projects
designed to measure risk. Since the Work
Plan covers a wide variety of issues and
provider categories, the purpose of this article
is to highlight those issues that may be most
relevant to hospitals and physicians.
The enforcement environment
is intense
To put the usefulness of the Work Plan in context,
it is first helpful to consider the ongoing
efforts and successes of HHS and the DOJ to
combat health care fraud and abuse. In 2004
alone, HHS and the DOJ won or negotiated
more than $1.5 billion in enforcement
actions. 3 Also in 2004, the U.S. Attorneys’
Offices opened 1,002 new criminal health care
fraud investigations involving 1,685 potential
defendants; federal prosecutors handled more
than 1,625 criminal health care fraud investigations
involving 2,361 defendants; and filed
criminal charges in 395 cases involving 646
With the increase in enforcement and criminal
actions for health care fraud and abuse, it
has become increasingly important for organizations
to pay close attention to issues
proactively raised by either HHS or DOJ,
such as those listed in the OIG’s Work Plan.
It is also important for providers to recognize
that many of the target areas articulated in
the Work Plan are often initially identified in
OIG and DOJ enforcement actions. For
example, by the end of fiscal year 2004, several
False Claims Act settlements were
reached in cases involving the submission of
dialysis claims. Correspondingly, the 2006
Work Plan identifies a “new area” of interest
as payment for “observation services” versus
“inpatient admissions” for dialysis services. 4
Work Plan—a critical compliance tool
As a general matter, a well-designed effective
compliance program will identify and reduce
risk, improve internal controls, and measure its
own effectiveness. First, an organization must
identify those risks deriving from its relationship
with federal and state health care programs.
This process will involve a proactive
and prospective examination of the risk for
abuse that exists within the organization.
Second, as an organization identifies and
assesses its risk it must take action to fortify
internal controls and processes to minimize
those risks. Third, the organization must evaluate
on an ongoing basis whether it has been
successful in addressing those risks. The Work
Plan serves as an excellent resource on which
compliance officers may review their organizations’
compliance objectives to align or realign
Continued on page 6
January 2006
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