OIG big-wigs review fraud prevention basics

Healthcare providers can take four steps to avoid allegations of fraud against their organizations, said leaders in the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services at the July 16 Regional Health Care Fraud Prevention Summit in Miami.

1. Understand and comply with the law. While that may sound easy, there are criminal, civil and administrative laws that are all intended to prevent fraud in the nation's healthcare system, said Chief Counsel Lewis Morris. "But I can offer a simple test that you can use to ensure that you understand and comply with the law. We call it the newspaper test: Don't do anything that you wouldn't have appear on the front page of the Miami Herald. If you use that simple test, you pass the first step in understanding and complying with the law."

2. Create a culture of compliance. An effective compliance program "helps identify overpayments and underpayments, helps resolve potential problems quickly, and minimizes the risk of whistle blowers," said Morris. "And most importantly, an effective compliance program helps you sleep better at night."

Soon the Medicare program will require all providers to have compliance programs, he noted. The OIG has resources available to help providers develop compliance programs.

3. Self-disclose problems. Providers can "become a partner in fighting healthcare fraud by self-disclosing problems to the government," said Morris. "An effective compliance program promotes a culture of integrity. It trains employees how to conform to program rules and regulations. An effective program also ensures that there are internal audits and reviews of billing and other requirements. If you are doing all those things, it's inevitable that you will find billing errors, employee misconduct and maybe even fraud in your company or healthcare system. The law requires that you return those government funds that you're not entitled to. Hiding the problem won't work--and only provides a breeding ground for whistleblowers. So the Inspector General's office has set up a self-disclosure protocol to encourage providers that identified problems to come forward and work with us to get the problems resolved equitably and quickly. CMS also is developing a self-disclosure program because it also believes that we should be partnering and identifying these problems promptly and resolving them equitably."

4. Maintain quality of care. While Morris didn't specifically cite quality of care as an issue, Inspector General Daniel Levinson did so in strong terms. "We need to make sure we are getting value. Quality of care is just as important as anything else we possibly do," he said. "When we are paying for a good or service, it has to meet professional standards, or it's really not a valuable, valid good or service at all."

To learn more:
- read this HHS press release
- watch the Summit videos
- read Attorney General Eric Holder's remarks
- visit the Stop Medicare Fraud website
- visit the OIG compliance guidance webpage