Kusserow on Compliance: OIG Strategic plan outlines top priorities for 2020 – 2025

 The HHS Office of Inspector General (OIG) has identified seven major initiatives as part of its strategic plan for the period between 2020 and 2025. The initiatives include: (1) fraud and abuse protections; (2) safeguarding the Medicare trust funds; (3) protecting beneficiaries from prescription drug abuse; (4) combating health care cybersecurity threats; (5) promoting patient safety and accuracy of payments in home and community settings; (6) leveraging technology; and (7) ensuring HHS managed care and new health care models produce value.

  1. Fraud and Abuse Protections. OIG audits of national Medicaid data found substantial improper payments to providers for Medicaid Services; states were not always correctly determining lack of eligibility of individuals for Medicaid benefits. These two areas will be a focus for OIG oversight.
  2. Safeguarding the Medicare Trust Funds. The OIG plans to use data analytics to identify program areas and geographic areas of high-risk. It should provide strategic oversight of emergency preparedness and response affecting Medicare beneficiaries, Medicare Advantage, prescription drug spending, and the transition to value-based care.
  3. Protecting Beneficiaries from Prescription Drug Abuse, Including Opioids. The OIG’s efforts will focus on identifying opportunities to improve the efficiency and effectiveness of monitoring and identifying and holding accountable those engaged in fraud and abuse related to prescription drugs. Major efforts will include empowering partners through data sharing and education.
  1. Combatting Health Care Cybersecurity Threats. The OIG will increase efforts to combat cybersecurity threats, including hacking attacks, manipulation of medical devices, and inappropriate access to U.S. genomic data. The OIG will perform more cybersecurity audits of HHS agencies and programs, in partnership with other agencies, to conduct investigations that may involve espionage or foreign threats.
  1. Promoting Patient Safety and Accuracy of Payments in Home and Community Settings. The OIG plans increased efforts to reduce improper payments for services in noninstitutional settings, including home health. The OIG’s plans include outreach, education, audits, evaluations, inspections, investigations, and administrative enforcement.
  1. Leveraging Technology as it Intersects with HHS Programs. The OIG highlights that technology can be used to increase the efficiency, quality, and accessibility of the health care system. The OIG will work with other HHS agencies, patients, and providers to educate and oversee the use of health technology to positively impact providers and patients. The OIG will also assess how it can use Artificial Intelligence to foster value and quality in HHS programs.
  1. Ensuring HHS Managed Care and New Healthcare Models Produce Value. As CMS programs shift to value-based care and payment, the OIG has identified three elements that are critical to achieving better value, quality, and outcomes: (1) aligning program incentives with improved health outcomes; (2) strengthening program integrity; and (3) delivering innovative technology. The OIG will oversee the continued transition to value-based programs and will address and combat any issues of fraud, waste, and abuse.

 

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 LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2020 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: DOJ, OIG promote a ‘Culture of Compliance,’ Strategic Management can help

The Department of Justice (DOJ) “Evaluation of Corporate Compliance Programs” notes that an effective compliance program includes “[t]he company’s culture of compliance.” It also states it is important for a company to create and foster a culture of ethics and compliance with the law and for executive leadership to implement a culture of compliance from the top. The DOJ calls for its prosecutors to assess whether the company has established processes that incorporate the culture of compliance into its day-to-day operations. The OIG stresses similar points in its Compliance Program Guidance by stating that compliance efforts need to be designed to establish a culture that promotes prevention, detection and resolution of instances of conduct that violate applicable laws, regulations, health care program requirements, and ethical and business practices. The OIG further advises that consideration should be given to using questionnaires that solicit impressions of a broad cross-section of employees and staff. Elsewhere the OIG recommends evaluations of compliance program through “employee surveys.” The U.S. Sentencing Commission Guidelines notes the importance of organizations to develop institutional compliance cultures that discourage criminal conduct and that an effective compliance program must “promote an organizational culture that encourages ethical conduct and a commitment to compliance.”

Solution to Measuring and Benchmarking Compliance Culture

Since 1993, Strategic Management has employed its healthcare compliance culture benchmark survey, on behalf of hundreds of health care organizations with more than three quarters of a million surveyed population. It was developed by a former DHHS Inspector General with the assistance of two PhD experts. The survey design measures employee attitude and perceptions concerning the compliance environment; and has been tested and validated to provide reliable results. The huge database of users permits organizations to benchmark their results against that universe. The results provide invaluable metrics of program effectiveness and can establish a baseline from which future surveys can be used to benchmark improvement. The report provides insights into how effective the compliance program has been in changing and improving the compliance culture of an organization. Employing this tool is surprisingly inexpensive and costs only a small fraction of a full compliance program effectiveness evaluation or even gap analysis.  They are also less costly than developing and delivering a home grown survey that are not validated or tested for reliability. Reports from the Survey runs 30 to 50 pages and include tips for addressing any weaknesses; and benchmarks results against the huge universe of those who have used the same survey three ways: (a) overall results, (b) by category, and (c) individual questions.

 

For more information on a Compliance Culture Survey, contact Kash Chopra, JD (703-535-1413) or at  KChopra@strategicm.com .

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 LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2020 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: New COVID-19 scam warning from the FBI

Some providing false test results to get off work

Causing business to shut down and unnecessary quarantining

Further crippling some businesses

The FBI has issued a series of warnings about a rise in coronavirus-inspired scams that have emerged in recent weeks. The latest warning cautioned employers to be on the lookout for employees using falsified doctors notes and other medical documents claiming they tested positive for coronavirus. The FBI cited once case where a worker at a critical manufacturing company submitted a letter that appeared to come from a medical facility and showed a positive COVID-19 test result. In response, the company shutdown a manufacturing site to disinfect the facility and halted production and delivery of necessary materials. The company also notified all workers at the facility, including four people who had to be quarantined because they had close contact with the infected employee. The FBI’s advice to employers is to be on the lookout for inconsistencies in medical documentation from employees and to contact medical providers listed on medical documents to verify the information. The importance of verifying employees who test positive will become more important as more business activity will be reactivated by government authorities.

Kusserow on Compliance: FBI reports rise in schemes involving the COVID-19 pandemic

The FBI reported that fraudsters are taking advantage of COVID-19 pandemic to steal your money, personal information, or both. Fraudsters see a vulnerable population scared and looking for help to protect themselves and their families. They are increasingly resourceful and view the current crisis as an opportunity to advance their schemes. Today, many are looking for medical attention, equipment, and supplies. As a result, a new fraud threat involves fake cures or treatments for the virus, many of which can be extremely dangerous or even fatal.

People who are at home and out of work are vulnerable to work-from-home scams where up-front money is requested—such requests are not something a legitimate employer does. One of the most prevalent schemes is where criminals make contacts pretending to be from the government to require mandatory COVID 19 testing in order to gain personal information, money, or to hack into a computer. Other scams involve acquiring personal information under the pretense of determining eligibility to receive government benefits. In some cases, fraudsters are even going door-to-door to try to convince individuals that they need to provide money for COVID-19 testing, financial relief, or medical equipment. The FBI has teams of agents working on these cases and have arrested and filed charges against many engaging in these crimes. They FBI advises everyone to be on the lookout for the following “red flags” involved in email contacts:

  • Unexplained urgency
  • Last minute changes in wire instructions or recipient account information
  • Last minute changes in established communication platforms or email account addresses
  • Communications only in email and refusal to communicate via phone or video
  • Requests for advanced payment of services when not previously required
  • Requests from employees to change direct deposit information

The following tips have been offered to help protect against these schemes:

  1. Be very wary of any attachments or links.
  2. Be suspicious of anyone offering you something that’s “too good to be true”
  3. Beware of contacts purporting to be a government agency requiring taking a COVID-19 test
  4. Beware of individuals offering to sell you a COVID-19 test kit or supplies
  5. Beware of medical professionals requesting payment for treating a friend or relative
  6. Be skeptical of last-minute changes in wiring instructions or recipient account information
  7. Verify addresses of emails from those you know; it may be just one letter difference
  8. Never contact a vendor solicitation via the number provided in the email
  9. Ensure URL in emails is exactly as seen in the past for the business it claims to be from
  10. Be alert to hyperlinks that may contain misspellings of the actual domain name
  11. Accept a medical treatment or virus test only from known doctor or pharmacist
  12. Use extreme caution in online communication
  13. Seek out legitimate sources of information and not accept what is sent without request

For more information, the HHS OIG issued a COVID-19 Fraud Alert Video to warn about several health care fraud scams.

 

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 LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2020 Strategic Management Services, LLC. Published with permission.