The recently released 2014 work plan sets up how the Inspector General’s office of U.S. Department of Health and Human Services will scrutinize claims CMS pays to hospitals, nursing homes, and home care agencies, as well as for prescription drugs, medical equipment and other care services. Continue reading
To draw attention to its ongoing monitoring of the incidence of adverse events in US hospitals and the accurate reporting thereof, the HHS Office of Inspector General is highlighting a roundup of reports on the subject.
If you get a chance to read it, you’ll probably see why I decided to distill it to a bulleted list of somewhat remarkable numbers.
Here goes:
For those looking to dig deeper and better understand the adverse events and how they’re reported, the OIG refers to a number of relevant reports. Journalists will be particularly interested in reports explaining how reporting requirements have failed, as it helps explain the limitations of currently available data sets.
A just-issued 31-page guide for new physicians from HHS’ Office of the Inspector General teaches doctors how (and why) to avoid defrauding their patients and the federal government. As their public-facing antifraud campaign ramps up, the office is responding to a need for better education of medical students. It makes sense, as physicians are generally the gatekeepers for medical spending. The government doesn’t often restrict their actions on the front end, which means physicians need to know the rules before they act.
The guide is fairly engaging reading, as OIG reports go, and it may serve as a primer to reporters looking into Medicare and Medicaid fraud. It covers doctors’ relationships with payers, other providers and vendors, as well as a summary of the five primary anti-fraud statutes.
False Claims Act
Doctors shouldn’t submit claims they know are wrong, or they’ll get socked with an $11,000 fine for every little item billed falsely, in addition to repaying the cost of the item several times over. This includes upcoding, or billing for a more severe (and expensive) illness than the patient really had, or billing for an item already included in a larger overall reimbursement.
Anti-Kickback Statute
Don’t pay for patient referrals or anything else that generates business. And yes, all forms of payola are covered, not just cash.
This also extends to getting paid, whether it be by pharmaceutical companies or the college buddy who’s getting all the referrals.
Note: Doctors can waive patient copays in specific situations (they’re uninsured, can’t afford it or the doctor can’t collect), but physicians can’t do it systematically as a way to gain patients.
Physician Self-Referral Law (aka the “Stark law”)
With a couple of gigantic exceptions, doctors can’t refer patients to imaging centers that they or family members own. The rules also apply to physical therapy, prosthetics, home health services and hospital services, among other things.
Physicians can invest in health care business ventures, but they should look out for possible conflicts of interest, especially if they’re getting the sort of preferential treatment not afforded to ordinary investors.
Red flag: If the money you’re getting paid is out of proportion to the work you’re doing, then something shady is probably going on. Especially if it in any way influences the treatment your patients get.
Remember, nearly all gifts and payments from drug and device companies will be disclosed starting in 2013.
Exclusion Authorities
Doctors shouldn’t deal with folks who have already been convicted of Medicare or Medicaid fraud, patient abuse or neglect, or any related offenses. If you don’t want to get on their black list, don’t violate the other four key fraud laws.
Civil Monetary Penalties Law
CMS can seek civil monetary penalties (and black listing) if doctors violate any of the above, or provide them with false information. Physicians also need to provide adequate screening to emergency patients.
Finally, the guide ends with instructions for doctors on how to report themselves, emphasizing that doing so “allows providers to work with the Government to avoid the costs and disruptions entailed in a Government-directed investigation.”
Calling health care “a convoluted system that’s easy to game,” Kaiser Health News’ Andrew Villegas writes that despite recent federal proclamations of success in cracking down on Medicare fraud, CMS still needs a systematic claims review system instead of their current “ad-hoc” methods. For evidence, Villegas draws on an interview with Lou Saccoccio, executive director of the National Health Care Anti-Fraud Association.
What’s the one thing Saccoccio would like to see changed right away?
Let the the federal government share Medicare claims information with states and private insurers. “If you take all of that claims data that they have between Medicaid and Medicare and start analyzing it,” he said, “You [could] identify where problem areas are.”
The government does some of it now, he said, but strictly on an ad hoc basis. A change in that policy could allow real-time fraud identification to “stop that money before it goes out the door,” Saccoccio said.
The report mentioned above, a 72-page annual assessment of the government’s efforts to stop medical fraud conducted by the HHS Office of Inspector General, declares that about $2.5 billion came to the Medicare Trust Fund in 2009, most of it from anti-fraud work. That included $620 million from criminal fines, $482 million for “penalties and mulitple damages,” and more than a billion from “restitution/compensatory damages.” But my favorite part of the report isn’t the big ticket items, it’s the avalanche of anecdotes that comes afterward.
It’s a lot to sort through (pages 8 through 56, by my reckoning) so I’ve made the whole thing searchable here. Plug in your state or a specific pet topic (wheelchairs are particularly popular among the fraudulent claimers) and you’re likely to come up with at least one story of swashbuckling government fraud busting. Or at least what passes for “swashbuckling” in OIG-speak.
The Department of Health and Human Services Office of Inspector General’s latest report covers “CDC’s ethics program for special government employees on federal advisory committees” (53-page PDF), which is significantly more interesting than that sentence makes it sound. For the report, OIG went through conflict-of-interest disclosure forms filed in 2007 for 246 members of FDA advisory committees and found that a striking number of them were incomplete or not properly acted upon. On one hand, “federal bureaucrats are real sticklers when it comes to filing paperwork” is hardly a headline, but on the other hand,the CDC’s ethics agreements are key to preserving the integrity of the committee advisory process.
Here are a few highlights taken from the report:
- For almost all special Government employees, CDC did not ensure that financial disclosure forms were complete in 2007. CDC certified OGE Forms 450 with at least one omission in 2007 for 97 percent of SGEs. Most of the forms had more than one type of omission.
- CDC did not identify or resolve potential conflicts of interest for 64 percent of special Government employees in 2007. Sixty-four percent of SGEs had potential conflicts of interest in 2007 that CDC did not identify and/or resolve before it certified their OGE Forms 450.
- CDC did not ensure that 41 percent of special Government employees received required ethics training in 2007.
- Fifteen percent of special Government employees did not comply with ethics requirements during committee meetings in 2007.
Auditors found that measurable conflicts of interest existed in many cases (58 percent) that had, nonetheless, been approved unresolved by CDC officials.
