Kusserow on Compliance: OIG report on 2017 Hotline activity

The HHS Office of Inspector Genera (OIG) is mandated to provide a semiannual report to Congress to summarize its activities. Included in this report was a section on the OIG Hotline (1-800-HHS-TIPS), available to individuals to report fraud, waste, or abuse in HHS programs.  The OIG considers the hotline a significant avenue of intelligence. What it also underscores is that many more “Whistleblowers” contact the OIG directly, than by filing qui tam actions with the DOJ. During the second half of 2017 alone, the OIG Hotline received 58,110 hotline contacts which were evaluated to determine whether an issue rises to the level of a complaint and whether it falls within OIG’s jurisdiction. Of that 13,781 were sufficient in details to warrant evaluation. The hotline phone was the source for 5,815 of these cases with another 3,966 obtained via the OIG website.  In addition 1,107 complaints were obtained via letter or fax. After evaluation, 10,888 were referred for action. The balance did not provide basis for further action or were found to not provide evidence of violations. The source of those tips that were referred for action varied.  Those received via the hotline phone were 5,127.  The internet was the source for 3,768 tips with the remaining 1,075 tips coming from letters and facsimiles.

The OIG forwarded approximately one-third of the complaints to its field offices for follow-up, slightly less than half to CMS, with the balance referred to other HHS operating divisions and other federal agencies. During this semiannual reporting period, the OIG Hotline reported expected recoveries of $9.9 million as a direct result of cases originating from hotline complaints.

Jillian Bower, has assisted scores of clients with their hotline operations through the Compliance Resource Center (CRC). She notes that having an effective hotline program is a must for any effective compliance program, however many organizations with hotlines that are not effective.  Those not promoting an effective hotline operation are making a grave error and risk driving complainants externally to the DOJ and OIG, litigating attorneys, media, etc. and that can only spell trouble. Receiving and resolving issues internally is the right approach and is good for the organization on many levels. Failing to do so can result in potential liabilities, headaches, and a lot of remedial work. By maintaining such a positive culture for employees to be able to report problems, concerns, and perceived wrongdoing will encourage internal reporting rather than having individuals thinking they must resort to “whistleblowing” to external parties.

10 Practical Tips

  1. Develop and implement written guidelines relating to the hotline operation that should information on the (a) hotline operations, (b) duty to report, (c) non-retaliation, (d) anonymity, (e) confidentiality, (f) investigations of complaints, among others.
  2. Have information about the use of the hotline made part of the Employee Handbook and Code of Conduct.
  3. Promote a culture that encourages employees to raise concerns and report perceived problems with managers being counseled that these are opportunities for improvement in the organization.
  4. Maintain a confidential recordkeeping system to enable a review of employment history for those employees who have raised concerns or reported problems.
  5. Have posters on the employee bulletin boards for the availability and use of the hotline.
  6. Ensure the hotline number and its availability is included in new employee orientation.
  7. Consider having a flyer go out to all employees on the availability of the hotline.
  8. If there is an Intranet for employee use, include information about the hotline.
  9. If there is an organization newsletter, use it to promote the hotline.
  10. Extra care needs to be taken to avoid doing anything that might be interpreted as retaliatory.

 

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: OIG adds six new projects in December to its Work Plan

In 2017, the HHS OIG moved to regularly update updating its Work Plan. In December, the OIG added six new projects that set forth various audits and evaluations that are underway or planned in the current fiscal year and beyond. In conducting its work, the OIG assesses relative risks in HHS programs and operations to identify those areas most in need of attention. In evaluating potential projects to undertake, the OIG considers a number of factors, including mandates set forth in laws, regulations, or other directives; requests by Congress, HHS management, or the Office of Management and Budget; top management and performance challenges facing HHS; work performed by other oversight organizations (e.g., GAO); management’s actions to implement OIG recommendations from previous reviews; and potential for positive impact. In addition to working on projects that often result in audits, reviews, and reports, the OIG also engages in a number of legal and investigative activities that are separately reported.

New Projects Added

  1. Status Update on States’ Efforts on Medicaid-Provider Enrollment. Provider enrollment is the gateway to billing in the Medicaid program. If this gateway is not guarded, Medicaid is at risk of fraud, waste, and abuse. Prior OIG work found many states had yet to complete fingerprint-based criminal background checks and site visits. CMS agreed with this and moved ahead to assist, however, CMS continues to extend the deadline for completion of fingerprint-based criminal background checks, indicating that states are still working on provider enrollment. The OIG plans to determine the extent to which states have completed fingerprint-based criminal background checks and site visits. For those not completing these steps, the OIG will inquire about challenges preventing them from completing this effort.

 

  1. Review of CMS Systems Used to Pay Medicare Advantage Organizations. CMS has designed its Medicare Part C systems to capture the necessary data in order to make increased hierarchical condition categories (HCC) payments to MA organizations. CMS is transitioning to a new data system to make these payments. The OIG will review the continuity of data maintained on current Medicare Part C systems, specifically instances in which CMS made an increased payment to an MA organization for a HCC and determine whether CMS’s systems properly contained a requisite diagnosis code that mapped to that HCC.

 

  1. State Compliance With Requirements for Reporting and Monitoring Critical Incidents. CMS requires states to implement an incident reporting system to protect the health and welfare of the Medicaid beneficiaries who receive services in community-based settings or nursing facilities. OIG previously found that some states did not always comply with federal and state requirements for reporting and monitoring critical incidents such as abuse and neglect. The OIG will review additional state Medicaid agencies to determine whether the selected states are in compliance with the requirements for reporting and monitoring critical incidents. The work will focus on beneficiaries residing in both community-based settings and nursing facilities.

 

  1. Paper Check Medicaid Payments Made to Mailbox-Rental Store Addresses. The CMS Medicaid Manual sets forth general federal requirements for adequate documentation of Medicaid claims. Potential providers are required to submit an application to bill for Medicaid services, and potential providers can choose to be paid by an electronic funds transfer (EFT) or a paper check. They must also list their practice and correspondence addresses. Because of theft, forgery, or alteration, the issuance of paper checks to providers carries more risk than using an EFT. The GAO reported identifying potential issues with Medicare-provider addresses and revealed that payments made to a provider with a mailbox-rental store, vacant, or invalid practice address increase the potential risk of fraud, waste, or abuse. The OIG will assess whether similar problems exist with the Medicaid program. Specifically, the OIG will determine if Medicaid payments issued by paper checks and sent to providers with mailbox-rental locations were for unallowable services.

 

  1. Prescription Opioid Drug Abuse and Misuse Prevention – Prescription Drug Monitoring Programs. Opioid abuse and related overdoses is a national epidemic and according to the Centers for Disease Control and Prevention (CDC), more than 33,000 people died in 2015 from overdoses involving opioids. HHS, through the CDC and the Substance Abuse and Mental Health Services Administration (SAMHSA), provides funding to States to prevent opioid abuse and misuse. Funding is provided by the CDC’s Prescription Drug Overdose: Prevention for States program and SAMHSA’s Strategic Prevention Framework for Prescription Drugs program. The OIG intends to identify actions state agencies have taken using federal funds for enhancing prescription drug monitoring programs (PDMPs) to achieve program goals—improving safe prescribing practices and preventing prescription drug abuse and misuse—and in doing so determine whether they complied with federal requirements. This series of audits will include states that have had a high number of overdose deaths, have a significant increase in the rate of drug overdose deaths, or received HHS funding to enhance their PDMPs.

 

  1. Impact of the Indian Health Service (IHS) Delivery of Information Technology/Information Security Services and Opioid Prescribing Practices. IHS has a decentralized management structure that is separated into two major categories: Headquarters and 12 Area Offices. The Area Offices are responsible for overseeing 26 hospitals, 59 health centers, and 32 health stations, some of which are located in remote locations. The OIG found that hospitals with limited cybersecurity resources struggle to implement information technology improvements and update the IHS electronic heath record system. The OIG will analyze and compare information technology/information security (IT/IS) operations and opioid prescribing practices at five IHS hospitals to determine whether (1) IHS’s decentralized management structure has affected its ability to deliver adequate IT/IS services in accordance with federal requirements and (2) hospitals prescribed and dispensed opioids in accordance with IHS policies and procedures.

 

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: GAO expects increase in fraud investigations in 2018

In report entitled “Medicare CMS Fraud Prevention System Uses Claims Analysis to Address Fraud”, the Government Accountability Office (GAO) noted that 65 percent of providers were subject to prepayment review with 654 new Fraud Prevention System (FPS) new investigations in Fiscal Year (FY) 2016. CMS is responsible for conducting program integrity activities intended to reduce fraud, waste, and abuse and they are relying upon the FPS and other CMS information technology (IT) system to meet this responsibility.  More than one out of five fraud investigations have been based on leads generated by Medicare claims data analysis.  Also, FPS edits last year resulted in the denial of 324,000 claims and saved more than $20.4 million. FPS analyzes Medicare claims to identify health care providers with suspect billing patterns for further investigation and to prevent improper payments. The analysis is done using a set of models that develop leads for investigators and execute automated payment edits. Leads are created by looking at billing patterns, such as a disproportionate number of services in a single day from a single provider.  The CMS FPS helped stopping billions of dollars in improper payments. Now 20 percent of the Zone Program Integrity Contractors (ZPIC) fraud investigations began with a FPS lead and this is expected to increase as CMS with the continued roll out of the FPS and changes program integrity contractor requirements for using FPS with the transition from ZPICs to Unified Program Integrity Contractors (UPICs)

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: The value of surveying compliance professionals

There is great value of knowing where you are in relation to others

When asked to participate in surveys, it is worthwhile to know its purpose and why it is worthwhile to participate in one. In short, surveys are a method of gathering information from individuals. They can serve a variety of purposes. The survey should be considered as another confidential communication channel that permits sharing information with others in the compliance arena. The objective of the Compliance Benchmark Survey designed for compliance professionals is to permit compliance professionals to participate as a network in understanding what challenges their colleagues in other healthcare organizations are facing and preparing for 2018. It is a data collection tool utilized to describe the current state of affairs facing compliance professionals in the real-world. As respondents share their thoughts and challenges anonymously with others, other compliance professionals benefit by knowing they are not alone in struggling to meet the challenges of compliance within their respective organizations.  The Survey taps into what compliance professionals are thinking and find useful information to assist in meeting challenges. Understanding what other compliance professionals are thinking and doing can assist in planning ahead to address the evolving challenges and expectations in an ever changing regulatory and enforcement environment. Results from the Survey can help proactively identify and respond to trends and issues confronting compliance professionals. This in turn may lead to a decision to shift priorities.

 

Benefits of Survey Participation

 

  1. It permits benchmarking your compliance efforts with other professionals at other healthcare organizations and gaining insights into developing a more effective compliance program.

 

  1. By participating in the Survey respondents will receive the analytical report of the results and a “free ticket” to a webinar hosted by a panel of compliance experts providing added feedback as to the significance of data collected and how it can be used in planning work for the upcoming year.

 

To join the network of compliance professionals in sharing their experience and concerns about meeting the challenges in 2018, click below:

 

Participate in the Survey

 


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.