Fraud Enforcement Risks and Compliance Solutions Katie Arnholt Deputy Branch Chief Office of Counsel to the Inspector General

Overview 1.Introduction to OIG/HHS 2.Common areas of fraud enforcement 3.Compliance tactics to address those risks areas

Office of Inspector General OIG Mission: to reduce fraud, waste, and abuse in HHS programs OIG role in health care fraud investigations and enforcement actions

CMS Contractors Differences between – Medicare Administrative Contractors – Recovery Auditors – Zone Program Integrity Contractors – OIG

Skilled Nursing Facilities and Nursing Facilities Common risk areas: – Medically unnecessary and inappropriate rehabilitation therapy – Systemically substandard care – Receipt of kickbacks for referrals

Home Health Common risk areas: – Services to ineligible beneficiaries – Lack of or falsified face-to-face encounter forms – Medically unnecessary and inappropriate rehabilitation therapy – Billing for services not rendered – Kickbacks for referrals

Hospice Common risk areas: – Services to ineligible beneficiaries – Lack of or falsified physician certification – Medically unnecessary level of service

Compliance Tactics Nursing Homes – Oversee your therapy contractor Do they have an incentive to inappropriately increase therapy minutes? – Monitor the care provided Visit facilities, ensure appropriate staffing levels and competency, monitor data for potential issues – Review agreements with ambulance providers and LTC pharmacies for kickbacks

Compliance Tactics Home Health and Hospice – Ensure admissions process is working All required documentation Initial eligibility Continued eligibility – Monitor whether care provided – Review agreements with referral sources for kickbacks

Compliance Tactics General Tactics – Demonstrate commitment to compliance – Engage Board of Directors – Ensure Compliance Officer has independence and resources – Develop risk assessment and internal audit program – Foster internal reporting without fear of reprisal – Regularly screen against the List of Excluded Individuals and Entities

OIG Resources oig.hhs.gov – Compliance Program Guidances – Compliance tools for Boards – Corporate Integrity Agreements – Advisory Bulletin on Effect of Exclusion – Audits and Evaluations by provider type – 2015 OIG Work Plan – 2014 Top Management Challenges – Self-Disclosure Protocol

Questions?