Kusserow on Compliance: OIG reports Medicaid Fraud Control Units results for 2016

The HHS Office of Inspector General (OIG) is the designated Federal agency that oversees state Medicaid Fraud Control Units (MFCUs). It issued a report on their statistical results for 2016. MFCUs are charged with investigating and prosecuting patient abuse or neglect in nursing homes and hospitals, as well as in assisted living facilities. Seventy-five percent of MFCU funding comes from the federal government. The OIG administers the grant to each of the units, sets performance standards, reviews each state’s program, provides technical assistance identify best practices, and collects and analyzes statistics. There are MFCUs in 49 states and the District of Columbia with funding of $258,698,147. With a staffing of 1,965 investigators, auditors, and attorneys, they investigated 15,505 fraud cases and another 3,221 abuse and neglect cases. This resulted in 1,564 criminal convictions and 998 civil settlements. They also achieved a total $1,876,532,842 in monetary recoveries with $368,498,733 from criminal actions, $1,225,709,487 in civil settlements, and $282,324,622 from other actions.  MFCUs most often work their own cases without assistance from other agencies. The OIG works a lot of cases with the MFCUs and in 2016, these cases resulted in 312 indictments, 348 criminal actions, and 222 civil actions. These Medicaid cases–some of which also involved Medicare–resulted in almost $3 billion dollars in expected recoveries.

The results of individual units can be found in the OIG report, along with a more detailed statistical breakdown of data. For comparison in results, the OIG issued a detailed report for 2015, noting that the MFCUs achieved 1,553 convictions, 731 civil settlements and judgments, and $744 million in criminal and civil recoveries. In this report, the OIG provided a detailed breakdown of the types of cases and trending data.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2017 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Compliance officers being effective

Today, organization leadership wants to feel confident that its compliance officer is effective in guarding against government intervention, litigation, and other unwanted events that give rise to liabilities. The challenge is how to convince everyone they are effective in what they do.  Experts with years of experience as both compliance officers and advisory compliance consultants to organizations were asked to provide some insights and suggestions for compliance officers.

Al Bassett, J.D., is a retired Deputy Inspector General and nationally recognized expert on health care compliance programs who has worked on evaluating effectiveness of dozens of compliance programs. He believes that to be effective, the compliance officers must always be selling the benefits of a successful program, as well as the consequences for not having one, to the Board and executive leadership. Once they are on board, then the selling must continue with managers and first line supervisors, and finally with the rank and file employees, physicians, and medical staff.

Carrie Kusserow has 15 years’ experience as a compliance officer, interim compliance officer, and compliance consultant to many organizations. She agrees and says, without question, the biggest sales target has to the Board, in that once it is sold, executive leadership will follow suit. It needs to know and understand what is required of it by enforcement and regulatory agencies, as well as the personal risks for ignoring its fiduciary compliance oversight responsibilities.  The HHS Office of Inspector General (OIG), along with the American Health Lawyers Association, has been issuing ‘White Papers” on Board obligations.  The most recent was Practical Guidance for Health Care Governing Boards on Compliance Oversight. The OIG is now incorporating this guidance into mandates for the CIAs.

Tom Herrmann, J.D., retired from the HHS OIG Office of Counsel to the Inspector General (IG) and then became a compliance officer and consultant to many organizations. He states that once there is “buy-in” from leadership, it is important to cultivate sound working relationships with other functions that overlap with compliance, including human resources (HR), Health Information Portability and Accountability Act (HIPAA) (P.L. 104-191) privacy and security officers, legal counsel, and internal audit.  In far too many organizations, these functions operate at cross purposes with one another and engage in turf battles, so as to have a serious negative impact on compliance officer effectiveness. There is a need to focus on developing cooperation and coordination of effort, along with developing protocols (policy documents) that establish working relationships and methods of cooperative effort.

Steve Forman, CPA, is another veteran of the HHS OIG, where he served as Director of Operations; he followed this with more than twenty years’ experience as a compliance officer and consultant. He sees the most successful and effective compliance officers as having been able to convince first-line managers to carry the compliance message to their subordinates by word and example.  The words they say and the attitudes they project to their staff are powerful, more so than pronouncements from the compliance officer or even the executive leadership.  Compliance officers selling themselves as being effective can be quickly enhanced by personally meeting with and talking to first-line supervisors and managers about the compliance program.

Jillian Bower has worked with dozens of compliance officers in advancing their programs. She points out that it is important to maintain ongoing metrics to benchmark progress of the compliance program to reassure executive leadership and the Board that the compliance officer is being effective in protecting the organization from unwanted events or acts that could give rise to liabilities.   She has found that one of the most useful means of doing this has been employing a professionally developed and independent administered compliance knowledge survey that evidences employee understanding of the program. The best surveys are anchored in a large database to permit comparison to other health care entities; and used periodically they also can measure benchmarks and progress in the program and further evidence compliance officer effectiveness.

Kash Chopra, J.D., has worked with a number of clients with their compliance programs, in addition to have served as an interim compliance officer. She believes effective compliance officers are successful in promoting employee compliance communication channels, particularly hotlines, that ensure complaints and allegations are promptly investigated and resolved professionally. If the workforce does not believe the organization is receptive to its concerns and nothing happens to its input, the compliance officer and program will never be fully effective. In addition, the compliance officer needs to be visible and available to hear employee concerns.  Chopra believes in walking around and being available to talk with people about their jobs, thoughts, and concerns.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

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Copyright © 2017 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: DOJ issues guidelines on corporate compliance programs

In February 2017, the Department of Justice (DOJ) issued its“Evaluation of Corporate Compliance Programs,” which provides an explanation as to how compliance programs are evaluated by prosecutors. This 119-question resource offers great insights for compliance officers working to build and enhance their compliance programs. One thing to remember about these guidelines is that they relate to all industry sectors.   The Principles of Federal Prosecution of Business Organizations in the United States Attorney’s Manual describes specific factors that prosecutors should consider in conducting an investigation of a corporate entity, determining whether to bring charges, and negotiating plea or other agreements. These factors, commonly known as the Filip Factors, include “the existence and effectiveness of the corporation’s pre-existing compliance program” and the corporation’s remedial efforts “to implement an effective corporate compliance program or to improve an existing one.” The guidance was formulated to evaluate compliance programs after a violation has been discovered and examine the existing misconduct as the benchmark against which the compliance program will be evaluated. The Compliance Program Guidance is divided into 11 sections. Each category includes a list of questions the DOJ may consider when evaluating a company’s compliance program when it confronts corporate misconduct. The sections are:

  1. Analysis and Remediation of Underlying Conduct;
  2. Senior and Middle Management;
  3. Autonomy and Resources;
  4. Policies and Procedures;
  5. Risk Assessment;
  6. Training and Communications;
  7. Confidential Reporting and Investigation;
  8. Incentives and Disciplinary Measures;
  9. Continuous Improvement, Periodic Testing and Review;
  10. Third Party Management; and
  11. Mergers & Acquisitions.

The DOJ noted that in developing this document, it used the U.S. Sentencing Commission Guidelines. The document also relates back to a number of other DOJ reports, including the Yates Memorandum that focused on individual accountability in corporate investigations, and not just organizational wrongdoing. Although the compliance guidance documents issued by the HHS Office of Inspector General (OIG) are tailored to the health care sector, the reading of the DOJ evaluation document is relatable to them. All seven elements of an effective compliance program are included in the DOJ guidelines. It is worthwhile for compliance officers of health care entities to read this document and incorporate those areas identified by the DOJ for their own work place. There are plenty of ideas among the 119-questions outlined in their document for use by compliance officers to improve their organizations’ compliance programs.

Tip

The OIG calls for ongoing monitoring of the compliance program to ensure that it is up to date and operating the way it is designed to. In addition, there should be periodic, independent auditing of the program to verify that monitoring is taking place and validate that the results of operation are making the compliance program effective in achieving its goals. The U.S. Sentencing Commission in its standards for compliance and ethics programs also call for organizations to “evaluate periodically the effectiveness of the organization’s compliance and ethics program.” Now the DOJ is calling for the same thing.  As such, those organizations that have not had their compliance program subject to an independent compliance program effectiveness evaluation should consider having it now, incorporating the DOJ guidelines as part of their review.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2017 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: OIG hotline being used by scammers

The HHS Office of Inspector General (OIG) accepts hotline complaints by mail, telephone, fax, or online. However, the office emphasizes that it does not use its phone number for outgoing calls. The OIG has issued a Fraud Alert reporting that its Hotline telephone number is being used as part of a telephone “spoofing” scam targeting individuals throughout the country.  The office reported engaging in a criminal investigation of this activity and intends to present cases against perpetrators to the U.S. Department of Justice (DOJ) for prosecution.   It explained that scammers have been altering the appearance of the caller ID to make it seem as if the call is coming from the HHS OIG Hotline, 1-800-HHS-TIPS (1-800-447-8477). Scammers call individuals and represent themselves as HHS OIG Hotline employees and use a variety of tactics to obtain personal information, which can then be used to steal money from an individual’s bank account or for other fraudulent activity.

The OIG warns the public to be on guard and not to provide personal information to callers. Those who believe they may have been a victim of this spoofing scam should report that information to the HHS OIG Hotline or spoof@oig.hhs.gov. Complaints may also be submitted to the Federal Trade Commission (FTC) via 1-877-FTC-HELP (1-877-382-4357).  The OIG also made clear that it is still safe to call into the HHS OIG Hotline to report fraud; information it receives is evaluated by the Office of Investigations, which has 420 Special Agents throughout the country who are specially trained to conduct these investigations.

OIG tips to protect yourself

Do not verify your name or any other personal information to anyone unknown to you. no personal information should be given to unknown individuals, including any of the following information:

  • Social Security number;
  • date of birth;
  • credit card information;
  • driver’s license number;
  • bank account information; or
  • mother’s maiden name.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2017 Strategic Management Services, LLC. Published with permission.