Healthcare News & Insights

OIG revises Provider Self-Disclosure Protocol in favor of hospitals, docs

If a self-audit of your hospital uncovers a healthcare fraud scheme, it’s best to voluntarily notify the feds right away. Not only does it prevent the hospital from getting into more trouble, it can also be beneficial in terms of paying any associated penalties.
HealthLawThe Office of Inspector General (OIG) recently released written confirmation of a long-understood policy: Hospitals and other healthcare entities can get a break on the fines they have to pay if they self-disclose any instances of healthcare fraud to the feds.

In a revision of its Provider Self-Disclosure Protocol, the OIG explicitly states that healthcare organizations that willingly disclose any info about fraud will only have to pay back about one and a half times the specified damages. Usually in a healthcare fraud case, fines and penalties are much larger.
Another benefit laid out in the report: Healthcare entities that self-disclose fraud won’t usually be subject to following imposed integrity agreements as part of a settlement.

Eligible violations

Hospitals have traditionally made use of the Self-Disclosure Protocol to admit to wrongdoing. According to an article in Modern Healthcare, over one-third of the disclosures reported to the OIG since the protocol was created have been from hospitals. This far outnumbers the disclosures from all other healthcare entities.

For a hospital to be eligible for reduced penalties, the disclosure must make specific reference to the act or statute being violated by the offense. The offense must be large in scope, involving violations “of Federal criminal, civil or administrative law for which civil monetary penalties are authorized,” according to the OIG.

Typical issues that cause hospitals to voluntarily self-report fraudulent behavior are referenced in the report. Common violations include:

  • intentional submission of false claims
  • maintaining contracts with providers who have been excluded from billing federal healthcare programs, and
  • violations of federal anti-kickback and self-referral laws.

Self-reporting parties must acknowledge the potential violations, and demonstrate the willingness to financially settle the matter within the six-year statute of limitations for the Civil Monetary Penalty Law.

For violations that deal with a few overpayments or other small billing errors, or violations of the Stark Law, healthcare entities must instead report the issue to the Centers for Medicare & Medicaid Services (CMS), which will handle the problem under its own protocol for self-disclosure.

The OIG report details what hospitals need to do to make a disclosure report for each type of violation. Hospitals can easily submit any disclosures through a form soon to be published on the OIG’s website.

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