MD - Health Care Compliance Association

More documents

Recommendations

Info

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 4 Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
Join us for the following HCCA Audio Conferences Get the latest “how-to” information—tools and advice you can use daily without even leaving your office! Register on the HCCA Web site—www.hcca-info.org. You will receive an e-mail a few days before the conference with any conference handouts, and dial-in information and instructions. ➤ ➤ Medicare Coverage Review Speakers: Lisa Murtha and Ryan Meade January 12 and 19 ➤ ➤ Medicare Part D Speakers: James G. Sheehan and David Bloch January 23 HCCA Audio Conferences are a fast and easy way to aquire HCCB CEUs! Health Care Compliance Association • 888-580-8373 • www.hcca-info.org 5
Page 1 and 2: Volume Eight Number One January 200
Page 3: ASK ON THE LEADERSHIP ONCALENDAR JO
Page 7 and 8: in 2006 will assess hospital compli
Page 9 and 10: By Susan C. L. Theuns Editor’s no
Page 11 and 12: ■ ABNs were used for preventive c
Page 13 and 14: Figure 1: ABN Reference Guide Servi
Page 15 and 16: feature article Editor’s note: Th
Page 17 and 18: GJ: Yes. The Fraud, Waste, and Abus
Page 20: ■ There will be Compliance expert
Page 23 and 24: Here’s your chance to share your
Page 25: espective nonprofit law compliance
Page 29 and 30: suffix that identifies package size
Page 31 and 32: By José A. Tabuena JOSÉ A. TABUEN
Page 33 and 34: AP: As far as the Auditing and Moni
Page 35 and 36: that would provide the intelligence
Page 37 and 38: Case study of Dana Farber Cancer In
Page 39 and 40: JOSEPH M. WATT ■ Solicit staff an
Page 41 and 42: including the three objectives set
Page 43: expect a measurable impact of compl
Page 46 and 47: New HCCA Members ...continued from
Page 48: C ORPORATE C OMPLIANCE & ETHICS: G

MD - Health Care Compliance Association

Create successful ePaper yourself

Delete template?

Save as template?