The Office of Inspector General (OIG) will use a risk spectrum that accounts for a wide range of risk factors when evaluating exclusion decisions following provider misconduct, according to updated guidelines released by the agency on Monday.
According to the updated criteria, the OIG "evaluates healthcare fraud cases on a continuum," based on how likely a provider is to commit fraud again and the impact on patients. Lower risk individuals include those who self-disclose violations and cooperate with a subsequent investigation, while higher risk providers may face heightened scrutiny, or in rare cases, Medicare exclusion.
The OIG frequently uses corporate integrity agreements as a means of strengthening a compliance programs and enhancing oversight. Occasionally, however, the OIG will forgo the agreements if there was no patient harm or intent and the financial harm was low, or if there is a successor owner that came in after the fraudulent conduct occurred.
When determining whether a provider is high or low risk for noncompliance, the OIG considers several factors including the adverse impact on individuals, leadership involvement, prior fraudulent conduct and cooperation during an investigation. Additionally, entities that initiate disciplinary actions against individuals responsible for misconduct and devote additional resources to compliance will be considered lower risk.
Cases involving civil monetary penalties and program exclusions are expected to increase following a new 10-person litigation team that will focus specifically on these cases. The OIG has also hired a new compliance counsel to provide a "reality check" on programs and enforce updated guidelines.
To learn more:
- read the OIG update