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Joining forces in fighting fraud - EY - United States

New horizons: 2012 health care provider report

Joining forces in fighting fraud

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What are the main drivers of your company’s planned acquisition activity in your chosen market/country? (respondents could select two)

Automotive capital confidence barometer - Growth

1 Source: S&P Capital IQ, 11 April 2012

As your organization pursues collaboration with physicians and other medical providers, does legal counsel preview any proposed contractual arrangements to consider any potential violations of the Stark Law or Anti-Kickback Statute?

The US Department of Justice (DoJ) and Department of Health and Human Services continue to join with the Federal Bureau of Investigation and other federal, state and local law enforcement partners to uncover and prosecute health care fraud.

These collaborative efforts — coupled with the Administration’s tough stance against fraud and abuse — are yielding substantial returns. According to the DoJ, the federal government’s health care fraud prevention and enforcement efforts resulted in record-breaking recoveries of federal funds in 2011.

Considerations for your board and executive leaders

Regulatory compliance planning

  • Have you committed adequate resources to your organization’s regulatory compliance program? Does the program meet ACA requirements and published guidance from the Office of the Inspector General and other regulators on effective compliance programs for health care organizations?
  • Do you screen your employees, contractors and business partners to ensure that they have no history of regulatory or compliance violations? Do you have a “know your vendor” program that investigates potential vendors to confirm ownership, reputation and history?
  • Do your internal controls provide for central oversight and management of contracts in a way that permits effective compliance control of contracting risks?

Medicare and Medicaid Recovery Audit Contractors (RACs)

  • Have you conducted a gap analysis of your billing practices to assess whether your billed services and associated documentation meet medical necessity and coverage requirements?
  • Do you compare your organization’s utilization rates of certain procedures, particularly those covered by the RAC prepayment review demonstration, with those of local, regional and national peers? If risk areas are found, are you initiating procedures to mitigate any potential losses or delays in payment should your organization become subject to a RAC prepayment review?
  • Do you have a process in place for assessing any RAC denials and determining whether they should be appealed, with a focus on whether the claims meet Centers for Medicare & Medicaid Services (CMS) payment criteria?

Billing and error reporting

  • For how long does your organization maintain billing records? If CMS implements a 10-year look-back period, can your staff comply with request for documentation of the medical necessity and proper billing of old claims?
  • Does your organization have a process by which any noted billing errors, problematic contractual issues and other potential violations are promptly reported to an internal audit team that can rapidly assess any improprieties, and self-report them to appropriate governmental agencies?
  • Does your internal review process ensure that any claim overpayments are promptly identified and reported and that repayment can be made within 60 days of identification?

Stark Law and non-disclosure agreements

  • As your organization pursues collaboration with physicians and other medical providers, does legal counsel preview any proposed contractual arrangements to consider any potential violations of the Stark Law or Anti-Kickback Statute?

Charity care, community needs and tax exempt status

  • Have you assessed your organization’s charity care and financial assistance policies compliance with the new ACA requirements, and are you prepared to disclose all relevant information on the revised Form 990 Schedule H? Do board members review your charity care policy disclosures before filing Form 990? Are you prepared to complete your organization’s community needs assessment and report on your strategy to meet the needs identified? Do you measure community benefits by dollars spent and by return on investment, identifying the ongoing benefits of your efforts?


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Email Jonathan Weaver
Americas Provider Care Sector Leader

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