BP - Health Care Compliance Association

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Increased government oversight of managed care plans ...continued from page 59 Association (NHCAA) has certified over 200 individuals in the private and government sectors as Accredited Healthcare Fraud Investigators since 2002. NHCAA is a coalition of private payers and law enforcement agencies created to address health insurance fraud, Annual surveys of NHCAA member plans show that the typical respondent’s recovery-to-cost ratio is usually in the 2:1 range. n Reporting. Policies and procedures on how, when, and whom to report potential fraud and abuse in compliance with governmental expectations are essential. Establishing and documenting guidelines for reporting potential fraud by a government-contracted health plan are important parts of a compliant fraud and abuse plan. Not only should objective guidelines be put in place, the reporting function should be insulated from the influences of other business units whose interests may not be entirely congruent with respect to a provider, for example, engaged in abusive billing behavior but who otherwise is held in favor by the plan for whatever reason. n Risk prioritization. A governmentcontracted health plan should prioritize its monitoring and auditing activities based on risk assessments. This risk assessment and the resultant prioritization of auditing should be documented and should include specific reference to risk factors associated with the government plan at issue. These are the general elements of an effective outward-looking fraud and abuse function for any government-contracted health plan. CMS and state Medicaid-related agencies will undoubtedly come up with more exacting specifications, but Medicare and Medicaid health plans can anticipate that the above will comprise the core of their fraud and abuserelated compliance obligations. The independent business case There is also a business case to be made for provider-focused fraud and abuse programs by health plans. In the experience of private health insurance plans that have dedicated provider-focused antifraud programs, the average private payer recovers claims payments at an approximately 2:1 ratio to expenses. 26 Imputed savings (e.g., claims denials, effect of terminating a network provider for fraud) and deterrent effects further enhance the benefit side of the ratio. Another, albeit intangible, compliance-related benefit can result from a health plan’s establishing a vigorous externally-focused antifraud function. SIUs in health plans with strong antifraud programs tend to develop good working relationships with state and federal law enforcement types. Often, providers who defraud government programs simultaneously defraud private insurance plans and in a number of instances, law enforcement has included private insurance claims as part of a Medicare or Medicaid case. Those same law enforcement types in a given locality may be the ones asked to look at a health plan’s activities, when allegations of impropriety arise. A health plan’s historically strong working relationship with law enforcement can be a useful thing when it is the plan’s conduct that is under scrutiny. Conclusion In light of the converging requirements for fraud and abuse programs for governmentcontracted plans (whether Medicare or Medicaid) focused on providers and “downstream” entities, a plan’s actual performance in detecting and reporting fraud in its provider networks and beyond will soon be on the government’s compliance checklist. For instance, CMS will undoubtedly react to the GAO’s recent recommendation for increased auditing in this area and the HHS-OIG Work Plan expressly provides for reviews of plan sponsors’ fraud and abuse-related compliance. This is an evolving area of compliance and the related audit experience is minimal. Government contracted Medicare and Medicaid plans, particularly smaller to mid-sized plans that have not historically conducted robust antifraud operations, should consider whether their fraud and abuse programs are sufficient for purposes of monitoring, investigating, and reporting fraud and abuse by its providers and other downstream entities. Although the CMS and typical state Medicaid fraud and abuse requirements are a mix of the useful, the obvious, and the sometimes unreasonable, they are coherent enough such that government-contracted health plans should address these fraud and abuse issues in their overall compliance efforts in anticipation of increased audit and oversight activity in these areas and for sound business reasons. n 1. See “Prosecutors Look Beyond False Claims Act to Fight Health Care Fraud,” Health Care Daily Report, vol. 13, No. 66 (BNA April 7, 3008). 2. Pub. L. No. 108-173, 117 Stat. 2066 (2003). 3. Manual § 20 4. HHS-OIG FY 2009 Work Plan, at 36 (October 1, 2008). The Work Plan can be found at www.oig.hhs.gov/publications/docs/workplan/2009/WorkPlanFY2009.pdf 5. Manual § 50.2.1. 6. Manual § 70.1.2. 7. Id. § 70.1.3. 8. Id. § 70.1.4. 9. Id. § 70.1.5. 10. Id. § 70.1.6. 11. Id. § 50.2.1.2. 12. Id. § 50.2.1.2. 13. GAO, “Medicare Part D: Some Plan Sponsors Have Not Completely Implemented Fraud and Abuse Programs, and CMS Oversight Has Been Limited,” (GAO-08-760) (August 2008). 14. Id. at 6-7. 15. HHS-OIG, “Oversight of Prescription Drug Plan Sponsors Compliance Plans,” Report OEI-03-08-00230, available at www.oig.hhs.gov/w-new. asp (10-31-08 reports) (accessed November 4, 2008). 16. Id., Appendix II (Letter from CMS to GAO) (“[T]here have not been sufficient additional resources to allow the MEDICs to engage in the types of audit oversight activities originally envisioned at the onset of the program.”). 17. Fed. Register Vol. 72, No. 233 at 68706. 18. Id. 19. Guidelines, at 39-40. 20. Id. at 40. 21. Id. 22. See 42 U.S.C. § 1396d. 23. GAO Medicare Part D: CMS Oversight Report (GAO-08-760), at 22. 24. Manual § 20 (Overview). Id. 25. HHS-OIG, “Medicare Drug Plan Sponsors’ Identification of Potential Fraud and Abuse,” Report OEI-03-07-0380, available at www.oig.hhs. gov/w-new.asp (10-31-08 reports) (accessed November 4, 2008). 26. NHCAA Annual Survey, available to members. March 2009 60 Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
New HCCA Members The Health Care Compliance Association welcomes the following new members and organizations. Please update any contact information using the Member Center on the Web site, or e-mail Karrie Hakenson (karrie.hakenson@hcca-info.org) with changes or corrections. Hawaii n James F. Kahler, MBA PT COSC, Hale Makua n Patricia Lee, Kaiser Permanente n Ernest J.T. Loo, Goodsill Anderson Quinn & Stifel LLP Idaho n Steven Bradley Pitts, Attorney, Law Office of Steven Pitts, P.A. Ilinois n Judith Blacklidge, Loyola Univ Health Sys n Vivian Downing, BroMenn Healthcare n Phyllis Gedzun, Midwest Physicians Alliance n Ellen S. Green, RHIA CCS-P, Rush University Med Ctr n Karen A. Hawthorne, Children’s Memorial Hospital n Agnes Hernandez, RHIT, Rush University Med Ctr n Sarah D. Hocking, JD, Carle Foundation Hospitol n Kelly Barar Keeler, MPPA, Alexian Brothers Health System n Erin M. Kinahan, Lake Forest Hospital n Susan Kramer, Heart Care Centers of IL n Brad Masterson, RHIA, Southern Illinois Healthcare n Chris F. Palazzolo, CVS-Caremark n Joyce Shannon, MetroSouth Medical Center n Jeffrey N. Teske, JD, Advocate Health Care n Cozette Trela, Heart Care Centers of IL n Margaret Zonca, MS, MBA, JD, Northwestern University Indiana n Ms. Mary Pat McCallister, CPC MCS-P PCS, University Radiological Assoc n Lisa P. McDonough, CPC CCP, Humana n Kimberly Patton, DePuy Orthopaedics Inc n Ms. Faith L. Pottschmidt, IN Univ Iowa n Kathy Bamman, Genesis Health System n Suzie A. Berregaard, JD, NHA, SPHR, Hospice of Central IA Kansas n Shannan Flach, Wamego City Hospital n Terri Gehring, Memorial Hospital, Inc. n Denise L. Klimek, MT ASCP, Mercy Regional Health Center n Dan Roehler, Argus Health Systems Kentucky n Donna T. Astudillo, MBA CPC CCP MHP, Humana n Jamie A. Burnett, RN, Univ Physician Associates n Terri L. Clark, BA MHP, Humana n Carey Coleson, Humana Inc. n Shelly Denham, BSN, Univ Physicians Massachusetts Associates n Beth R. Belt, Deloitte & Touche n Derek Dennison, CPA, MBA, Twin Lakes n Kate Bolland, Health Dialog Regional Med Ctr n Rosa Chiacchierarelli, CHC, Healthdrive n Tracy Farley, Jewish Hospital & St. Mary’s Medical & Dental Practices HealthCare n Helen G. DeRosa, Fresenius Medical Care n Rhonda Hoffman, Jewish Hospital & St. NA Mary’s HealthCare n Deborah Drexler, UMass n Sharon E. Jones, NHC, Norton n Sheila Murphy Fireman, Harvard Pilgrim Healthcare HealthCare n Anthony Leachman, Jewish Hospital n Judith Flynn, Partners Home Care n Jeffrey T. Lewandowski, MBA MHP, n Eileen Gibbons Humana Inc n Linda S. Hanna-Casey, Caritas Christi n Ed Miller, Jewish Hospital & St. Mary’s Healthcare System HealthCare n Luke Igweobi, Dana-Farber Cancer n Elizabeth L. Muse, RN, BSN, CPC, Institute Norton Healthcare n David McLoon, Franciscan Hospital for n Stephanie L. Redfern, U of L Hospital Children n Ann Shircliff, CPC CCP PCS, Humana Continued on page 62 Health Care Compliance Association • 888-580-8373 • www.hcca-info.org n Furqan Siddiqui, MD, Univ of Louisville Hospital n Trinia Simmons-Hill, University of Louisville Louisana n John J. Finn, Ph D, Self-Client CommCare Corporation n Byron Johnson, Navigant Consulting, Inc n Phyllis Krebs, Lafayette General Med Ctr n Larry Smith, United Medical Rehab Hosp Maryland n Shallie Bryant, MedStar Health n Andrea B. Cherenzia, Care First BCBS n Mary Flanery, CPC, Medstar n Kristen Geissler, Navigant Consulting n Margaret E. Henry, Practice Dynamics Inc n Frederick R. Herman, Univ of MD Medical Center n Mark Loper, Coventry Hlth Care Inc n Shari LoPresti, Harford Primary Care n Sharon McNamara, BSN, JD RN, Erickson Retirement Communities n Michelle Russell, Catalyst Rx 61 March 2009
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Volume Eleven Number Three March 20
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Publisher: Health Care Compliance A
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incrementally, and CMS has made cle
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New developments in payment and pub
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Page 11 and 12: of privacy and infliction of emotio
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Page 19 and 20: The Jones Day/HCCA iPod ® Nano Giv
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Page 25 and 26: ASK LEADERSHIP Compliance Today Nee
Page 27 and 28: YOUR INFORMATION FYIFOR Declining e
Page 29 and 30: sampling methodology is vital in de
Page 31 and 32: Health Care Compliance Association
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