Safeguarding integrity through compliance and ethics

The war on health care fraud and abuse

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EY - Lewis Morris - The war on health care fraud and abuse

Federal agencies continue to innovate in the fight against health care fraud.

The use of sophisticated IT systems and increased information-sharing is accelerating the effort to identify abuses and reduce losses. As the government finds new ways to detect fraud and abuse (F&A), health care organizations will need to implement steadfast approaches — developing and maintaining corporate compliance programs for conducting business with integrity and in accordance with all laws and regulatory requirements.

Considerations for your board and executive leaders

For all health care organizations

  • Is your chief compliance officer at the table when business decisions are being made?
  • Does your organization have clear procedures in place so employees can safely report possible fraud and abuse concerns and ensure any reported issues are promptly and effectively investigated?
  • Do you have a designated individual responsible for following legislative and regulatory updates, both state and federal, to ensure you are kept informed of, and are in compliance with, all applicable laws? Does this individual follow pending legislation to help your organization proactively plan for changes that may affect you?

For providers

  • Is your organization effective in coordinating compliance and quality assurance functions to keep up with the linking of payments to patient outcomes — while ensuring that your policies and practices do not inadvertently violate any F&A regulations?
  • Does your organization conduct a robust self-assessment at least annually to evaluate its billing, coding and documentation efforts and, in particular, assess emerging trends?
  • Is your organization using innovative data analytics to identify areas of potential fraud for internal investigation?

For payers

  • Is your organization putting as much emphasis on assessing the compliance efforts of those providers it pays on behalf of Medicare and other governmental health care programs as it puts on maintaining compliance with its own contracts with Medicare and other government programs for which it processes claims?
  • Have you implemented any innovative approaches to investigating fraud and abuse? Have you used and analyzed the vast population of health data available within your organization to identify best practices as well as potential fraudulent activity? Do you follow the approaches your peers are taking to identify best practices that would be applicable to, and effective for, your organization?