RACs, PSCs, ZPICs, MFCUs, MICs, MRACs, OIG, DOJ, FBI, and Now. . . Patients?
(From LilesParker.com) I. Background The Department of Health and Human Services (HHS) has long used reports and complaints from affected patients to further investigate allegations of possible Medicare fraud, waste and abuse. Last June, it was reported that HHS was planning on implementing a "Mystery Shopper" program, with a Federal contractor posing as a potential patient when calling a physician to inquire about possible care. While HHS quickly abandoned this program, it is important to keep in mind that the Centers for Medicare & Medicaid Services (CMS) has actively promoted its "Senior Medicare Patrol" (SMP) program since 1997. II. Senior Medicare Patrol For over ...
HIPAA Audits Are Here – Make Sure Your Privacy Policy is Fully Compliant
(December 28, 2011): The Office of Civil Rights (OCR), an agency of the Department of Health and Human Services (HHS), is the central organization responsible for enforcing compliance with the Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA). As OCR’s website reflects, the agency: “. . [I]nvestigates complaints, enforces rights, and promulgates regulations, develops policy and provides technical assistance and public education to ensure understanding of and compliance with non-discrimination and health information privacy laws.” After witnessing the effectiveness of Medicare contractors in identifying and recovering improper payments, Congress chose to include a similar compliance measure for HIPAA privacy as part ...
Conducting Mock Audits
(November 2, 2011) Recent years have seen health care providers grow more weary of government audits, malpractice claims, peer review concerns and other actions which can create a legal nightmare for a provider. Understandably, the health care industry has redoubled its efforts to achieve better compliance with the numerous statutory and regulatory requirements with which it must contend. Drafting and implementing compliance plans, conducting a gap analysis and training your staff on compliance issues are important steps toward the peace of mind compliance can bring. But how do you know when you've done enough? In the end, the answer is that ...
The Next “Patient” You See May be an Undercover Physician Auditing Your Practice.
As the American Medical Association (AMA) recently reported on March 22nd, health care providers may find themselves subjected to “Secret Shopper” audits by fellow providers hired by the government conduct reviews and investigations. In a speech he made March 10th, President Obama expressed interest in a proposal by Senator Tom Coburn, M.D. (R-OK) to have physicians and other health professionals go undercover and pose as patients to root out fraud. Apparently, President Obama included it among with several other Republican proposals which were considered when the recently passed Health Care Reform Bill was enacted. Dr. Coburn tried to amend the Senate ...
The U.S. Sentencing Commission has issued proposed changes that may significantly impact compliance plans and compliance professionals.
An effective Compliance Plan can greatly reduce the likelihood that your practice or clinic will find itself in violation of criminal statutory and regulatory requirements. Should a violation still occur, Federal Sentencing Guidelines have long credited an organization's efforts to comply with the law. Notably, on February 9, 2010, the U.S. Sentencing Commission announced that a number of changes to the Federal Sentencing Guidelines has been proposed, at least one of which should be of considerable interest to your Compliance Officer and other members of its mangement team. The provisions of §8B2.1 of the Federal Sentencing Guidelines (Effective Compliance and Ethics Program) are generally ...
New York Medicaid Makes Compliance Program Mandatory
Chapter 442 of the Laws of 2006, which established the New York State Office of the Medicaid Inspector General (OMIG), also created a new Social Services Law § 363-d which requires that Medicaid providers develop, adopt and implement effective compliance programs aimed at detecting fraud, waste, and abuse in the Medicaid program. The purpose of directing Medicaid providers to implement a compliance program is to ensure providers establish systemic checks and balances to detect and prevent inaccurate billing and inappropriate practices in the Medicaid program. While the mandatory compliance requirements contained in Social Services Law § 363-d and 18 NYCRR Part 521, ...
Nurse Stands Trial for Reporting Allegedly Dirty Doctor
In a case out of Western Texas, a nurse is preparing to stand trial for felony “Misuse of official information” after she reported a physician at her hospital to the Texas Medical Board. An administrative nurse and Compliance Officer for a West Texas hospital allegedly witnessed a number of unorthodox and potentially improper actions by a physician. As medical professionals are obligated to do under Texas law, she first reported the physician to her hospital administrator, and then to the Texas Medical Board. She and another nurse assisting her were subsequently dismissed. The prosecution alleges that the nurse reported the physician, who already had a ...
New Compliance Initiative Issued by U.S. Sentencing Commission
The U.S. Sentencing Commission, the independent board tasked with promulgating Federal sentencing guidelines to the nation’s Federal courts, has issued a new proposed rule which would significantly decrease criminal penalties for corporations if they maintain an effective compliance plan. Under this new proposal, if corporations establish and utilize a compliance plan designed to address white-collar crime and employ a compliance officer with direct access to the company’s board of directors, the criminal penalties for upper-management wrongdoing stand to be lessened. The main goal of this new incentive system is to skirt the corporate officers and other upper-management staff who may be ...
Compliance Plans
HIPAA Audits Are Here – Make Sure Your Privacy Policy is Fully Compliant(December 28, 2011): The Office of Civil Rights (OCR), an agency of the Department...
New York Medicaid Makes Compliance Program MandatoryChapter 442 of the Laws of 2006, which established the New York State Office of the...
New Compliance Initiative Issued by U.S. Sentencing CommissionThe U.S. Sentencing Commission, the independent board tasked with promulgating Federal...
Read More Posts From This CategoryMock Audits
Conducting Mock Audits(November 2, 2011) Recent years have seen health care providers grow more weary of...
The Next “Patient” You See May be an Undercover Physician Auditing Your Practice.As the American Medical Association (AMA) recently reported on March 22nd, health...
Read More Posts From This CategoryCompliance Training
The U.S. Sentencing Commission has issued proposed changes that may significantly impact compliance plans and compliance professionals.An effective Compliance Plan can greatly reduce the likelihood that your practice or clinic will find itself in violation of criminal statutory and regulatory requirements. Should a violation still occur, Federal Sentencing Guidelines have long credited an organization’s efforts to comply with the law. Notably, on February 9, 2010, the U.S.... [Read more of this review]
Nurse Stands Trial for Reporting Allegedly Dirty DoctorIn a case out of Western Texas, a nurse is preparing to stand trial for felony “Misuse of official information” after she reported a physician at her hospital to the Texas Medical Board. An administrative nurse and Compliance Officer for a West Texas hospital allegedly witnessed a number of unorthodox and potentially improper actions by a physician. As... [Read more of this review]
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