OIG clarifies how to disclose health care fraud voluntarily

Revisions to the self-disclosure protocol seek to build on $280 million recovered by reporting potential instances of Medicare and Medicaid fraud to the federal government.

By Charles Fiegl amednews staff — Posted May 27, 2013

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Federal officials are attempting to make reporting potential fraud and returning overpayments less painful for practices and facilities.

In 15 years, more than $280 million has been returned to federal health programs through a self-disclosure process, where physicians and hospitals voluntarily report instances of false Medicare billing or anti-kickback violations. The Dept. of Health and Human Services Office of Inspector General has sought to revise the protocol to provide more transparency about the process, including what is expected from physicians and how to have a successful resolution, said Tony Maida, OIG deputy chief of the administrative and civil remedies branch in the Office of Counsel. Clearer guidance would help more physicians and practices disclose and settle instances of potential fraud.

For instance, the OIG publicly stated that a monetary resolution would include a minimum 1.5 multiplier for calculating damages — an outcome that had not been known publicly. Those settling fraud cases through a fraud investigation generally pay a higher multiplier than those who self-disclose, Maida said.

“It's part of the financial benefit of disclosing,” he said.

The revised OIG document also details how to disclose three common potential fraud cases reported to OIG: false billing; employing an individual on the OIG exclusions list; and potential anti-kickback statute and physician self-referral law violations. The additional guidance should make the process go more quickly for practices dealing with these situations, Maida said.

AMA offers suggestions

The American Medical Association provided the OIG with recommendations to update the protocol in August 2012. The AMA recommended that the OIG suspend the obligation to return overpayments within 60 days. The Centers for Medicare & Medicaid Services has proposed a regulation to suspend the requirement when a physician self-discloses potential fraud to the OIG, as long as the overpayment is returned in a timely fashion.

The OIG acknowledges the CMS proposal in the protocol. When the proposed rule is finalized, the OIG may issue additional guidance as needed, Maida said.

Confidentiality of disclosures was not addressed in the revised self-disclosure protocol. Anyone considering disclosing information to the OIG may decide against it because of confidentiality concerns, the AMA had stated.

The OIG cannot enter into confidentiality agreements during settlements, Maida said. Information reported to the office is subject to freedom of information laws. The OIG also publishes summaries of settlements so the health care community can see what is being reported and how settlements are structured, he added.

Compliance programs at physician practices or medical groups are designed to find and report potential fraud. Many at the OIG view those using the self-disclosure protocol as raising their credibility and integrity.

“Finding problems and reporting them to the government is an indication of having a good compliance program in place,” Maida said.

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OIG penalties after disclosing overpayment

Physician practices uncovering instances of potential fraud can achieve a more favorable outcome when disclosing systemic problems voluntarily, said officials with the Dept. of Health and Human Services Office of Inspector General. Practices face tougher penalties when the OIG initiates a fraud finding. In self-disclosure cases, the OIG sets at least a 1.5 multiplier on single damages and penalty thresholds:

  • $50,000 minimum to settle kickback-related disclosures.
  • $10,000 minimum for all other matters.

Source: “OIG's Provider Self-Disclosure Protocol,” Dept. of Health and Human Services Office of Inspector General, April 17 (link)

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External links

“OIG's Provider Self-Disclosure Protocol,” Dept. of Health and Human Services Office of Inspector General, April 17 (link)

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