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OIG, in its semi-annual report to Congress indicated increased attention to delivering high-impact results while streamlining oversight during fiscal year (FY) 2017. The latest report, posted November 30, covers OIG activities from April 2017 through September 2017.

The Department of Health and Human Services Office of Inspector General (OIG) announced in June that it would update the work plan monthly, to enhance transparency.

In the September 15 update to the Work Plan, the new items posted are several examinations of Medicaid programs, including a review of five states to determine the extent to which Medicaid managed care plans include behavioral health providers and whether enough providers are available to meet the needs of the Medicaid population in those states.

New compliance program guidance has been issued by the Fraud Section of the Department of Justice (DOJ), according to an article published in the AHLA Weekly. Although the “Evaluation of Corporate Compliance Programs” (Guidance) is not specific to the healthcare industry, it does provide a practical set of benchmarks against which the audit & compliance committee, in consultation with the general counsel and the chief compliance officer, can evaluate the effectiveness of the health system’s compliance program.

The Office of Inspector General (OIG) publishes annually a Work Plan describing new, ongoing, and revised areas within the U.S. Department of Health and Human Services (HHS) it will investigate throughout the year for potential fraud, waste, and abuse. It’s wise for providers to review this Work Plan and update their compliance plans accordingly. Here’s a summary of the areas within Medicare Part B on which the OIG plans to focus this year.

Q: Is it appropriate to use the encounter form/routing slip to code and bill, rather than to code and bill from the patient chart?

A: This question raises an important distinction between coding and billing. The only way to code a service is from the actual record of the service, but it’s possible to bill from an encounter form if the provider has already coded the service.

The American Health Lawyers association reported the following in its weekly Fraud and Abuse update:

The government won or negotiated more than $2.5 billion in healthcare fraud judgments and settlements in fiscal year (FY) 2016, the Departments of Health and Human Services (HHS) and Justice (DOJ) said in their Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2016 released January 19.

U.S. Attorney for the District of Maryland, Rod J. Rosenstein announced December 20 that Elma Myles pled guilty to defrauding Medicaid and other health benefit programs by conspiring to have durable medical equipment provider RX Resources and Solutions (RXRS) bill for supplies that were never provided or were medically unnecessary, and to overcharge for materials that were actually delivered.

Myles, who worked for RXRS as a biller, admitted to conspiring with the company’s President and Chief Executive Officer, co-defendant Harry Crawford, and others in connection with the scheme, a press release said. An analysis of RXRS billing revealed that from 2007 through 2014, Medicaid lost roughly $1.2 million just for incontinence supplies, the release said.

The Department of Health and Human Services Office of Inspector General (OIG) issued a policy statement December 7 increasing what constitutes a gift of “nominal value” to Medicare and Medicaid beneficiaries for purposes of avoiding civil monetary penalties.

Under Section 1128A(a)(5) of the Social Security Act, enacted as part of HIPAA:
A person who offers or transfers to a Medicare or Medicaid beneficiary any remuneration that the person knows or should know is likely to influence the beneficiary’s selection of a particular provider, practitioner, or supplier of Medicare or Medicaid payable items or services may be liable for civil monetary penalties (CMPs) of up to $10,000 for each wrongful act.

It’s a compliance risk, and it deprives your physicians of proper payment.

“Overcoding,” or reporting procedures and services not supported by the actual work performed (as described in provider documentation), is improper coding, and it’s a compliance risk. “Undercoding” — or failing to report the full extent of provided procedures or services — is an equally unsound practice.

If appropriate rules and system edits are in place, exclusionary modifiers are the link to unbundling liability.

Unbundling is a commonly asserted but often misunderstood fraud theory, even by coding experts. When evaluating potential unbundling as a fraud theory, it’s important to differentiate when separate reporting of services is simply correct coding and when it becomes a scheme to defraud.

The Office of Inspector General (OIG) has defined unbundling as occurring when a “billing entity uses separate billing codes for services that have an aggregate billing code” (65 F.R. No. 243, 70138, 70142).

According to an article posted in the National Law Review, the Health and Human Services Office for Civil Rights recorded close to $15 million in compliance related settlement payments through July of this year. The report notes that these settlements demonstrate OCR’s more aggressive posture in enforcing HIPAA regulations.