Re-evaluate and Update Your Compliance Plans

By Marla Durben Hirsch, Contributing Writer, G2 Compliance Advisor

The Department of Justice (DOJ) and the U.S. Department of Health and Human Services' Office of Inspector General (OIG) have been very active in fraud prevention and enforcement, recovering $3.3 billion in taxpayer dollars in fiscal year (FY) 2014. For every dollar spent, the government recovered $7.70, an "extraordinary" return on investment, according to the Departments' joint announcement. They will continue to escalate their efforts, using increased funding, new authority granted by the Affordable Care Act, more real-time data analytics, and continued use of the False Claims Act, which provided $2.3 billion in civil settlements and judgments involving the claims against the Medicare and Medicaid programs in FY 2014.

The government has also offered some guidance, however, too. In April, the OIG released a compliance guidance document created through the joint efforts of the OIG, the American Health Lawyers Association (AHLA), the Association of Healthcare Internal Auditors (AHIA) and the Health Care Compliance Association (HCCA). The document's purpose is to assist governing Boards of health care entities in their oversight of compliance plans.

Among the top risk areas highlighted in the guidance document, the first issue mentioned is referral relationships and arrangements—an issue of significant relevance to laboratories particularly in light of last year's fraud alert and current enforcement efforts targeting such relationships. Other risk areas highlighted were billing, privacy breaches and quality-related events.

Highlighting the potential for "new incentives and compliance risks" created by current health care reform efforts, the guidance notes: "New payment models have also incentivized consolidation among health care providers and more employment and contractual relationships (e.g., between hospitals and physicians)." Laboratory compliance professionals should heed the guidance's suggestion that "Boards of entities that have financial relationships with referral sources or recipients should ask how their organizations are reviewing these arrangements for compliance with the physician self-referral (Stark) and anti-kickback laws."

For more information about this guidance, tips for reviewing your compliance program, and resources for evaluating its effectiveness, click here to view the Compliance Perspectives feature originally published in the May 2015 issue of G2 Compliance Advisor.