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.

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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.

Kusserow on Compliance: Getting ready to evidence program effectiveness in 2018

In its compliance guidance, the HHS Office of Inspector General (OIG) calls for periodic evaluation of compliance program effectiveness. This can be done by a full field evaluation by experts, however, there are other methods that can help accomplish this end. One way to evidence effectiveness is measuring the compliance culture of the organization with a compliance culture survey. However, to obtain meaningful results requires using a professionally developed and independently administered instrument. Internally developed surveys have little value and are often considered suspect by those asked to participate in the process.

Dr. Cornelia Dorschmid, PhD, advises that a culture survey should be professionally developed, tested, and validated in order to obtain reliable and useful results with the best results being anchored in a larger database for comparison of results. She was instrumental in developing the Compliance Benchmark Survey©, along with a PhD behavioral scientist and a former HHS Inspector General that has been in use since 1993. It uses a Likert Scale model, wherein respondents are asked to rate the question on a scale of one to five. Mean scores are computed for each item. Some questions items are reverse-scored to control for response set (the tendency to respond in a given pattern), “halo effect”.  The survey also includes items known as validators that ensure that respondents are being candid in their responses and not trying to manipulate the survey.

Jillian Bower Concepcion, VP for the Compliance Resource Center explained that the Compliance Benchmark Survey© has been widely used by hundreds of health care organizations with more than a half million employees surveyed. Results of this survey will assist identifying compliance program strengths, as well as opportunities for improvement. Reports present employee perceptions with respect to five different dimensions and four compliance themes. The results by question, panel, and overall results can be compared and benchmarked against the universe of those who used the survey.  The overall score level (i.e., sum of individual item scores) of the company is evaluated against the Health Care Compliance Index (HCCI©). An organization using the same survey over time can also benchmark their progress and measure improvement in the organization’s culture. For more information on compliance surveys, see https://www.complianceresource.com/publication-topics/compliance-surveys/

Steve Forman, CPA, a nationally recognized healthcare compliance consultant whose experience includes serving as an executive in the OIG and the CCO for one of the nation’s largest healthcare system has used the Compliance Benchmark Survey© since it was first introduced.  He has found survey results assist in identifying areas where attention is needed that is very useful in the maintenance and enhancing an effective compliance-program. The results can tell you the “what”, but not the “why” and as such he uses the information in talking to employees and conducting “focus group” meetings that can provide additional insights as to the full meaning of the information derived from the survey.

Al Bassett, JD, is another nationally recognized expert on healthcare compliance, who has been building and evaluating compliance program for over 15 years. Prior to his work in compliance, he was a Deputy Inspector General and FBI executive. He noted that he has found the survey is very valuable in assessing compliance program effectiveness. Results provide compliance officers with a road map to improving the program effectiveness and the costs of using the survey in evaluating the compliance program is only about only 10 percent of a full field assessment by experts.

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 report on research compliance through OHRP

The OIG conducted a study of the Office of Human Research Protection (OHRP) at HHS in response to Congressional requests that raised questions about its independence. The request was for the OIG to review OHRP procedures and make recommendations to strengthen protections for human subjects and ensure OHRP’s independence. OHRP enforces compliance with HHS regulations for protecting human subjects. Its mission is to protect the rights of human subjects-individuals who volunteer to participate in research conducted or supported by the HHS. The OIG conducted a survey of research institutions that were the primary subjects of the compliance evaluations about their experiences with the OHRP. The OIG also reviewed documents from eight compliance evaluations that had been closed; and interviewed OHRP staff, other HHS officials, and individuals with expertise in protections for human subjects.

OIG findings regarding OHRP

The OIG found that OHRP:

  • evidenced carrying out its compliance activities independently from agencies funding the research and the institutions conducting the research;
  • made decisions on how to use resources, resulting in fewer compliance evaluations, while increasing its use of other mechanisms in response to allegations;
  • determined the scope of its evaluations and what methods to employ;
  • was able to access the information it needed to conduct its compliance evaluations;
  • maintained documentation on its determinations;
  • may be limited in its ability to act independently due to its role, placement within HHS, and the way its budget is set may limit; and
  • may have the appearance of limited oversight and independence due to the practice of not reporting publicly on all of its compliance activities.

OIG Recommendations to HHS

The OIG recommended that HHS:

  1. issue guidance that clarifies OHRP’s role;
  2. re-evaluate OHRP’s position within HHS;
  3. evaluate sufficiency of OHRP’s resources;
  4. consider ways to elevate the prominence of OHRP’s budget (e.g. having a separate line item in the President’s budget);
  5. foster a shared understanding for OHRP’s independence by considering seeking statutory authority for OHRP’s independence; and
  6. post on OHRP’s website: (a) a description of its approach to oversight and (b) data (in aggregate) regarding its compliance activities.

 

 

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.