February 1998

Health Care E-lert - Inspector General Issues Compliance Guidance, 2/17/98

2 min

The Office of Inspector General ("OIG") of the Department of Health and Human Services has published the long-awaited Compliance Program Guidance for Hospitals (the "Compliance Guidance "),released February 11, 1998.

The hospital industry has long known that the OIG views the implementation of compliance programs in hospitals as critical. For the first time, however, the OIG has provided a set of guidelines for a hospital to consider when implementing a compliance program. The OIG also identified 18 special areas of concern:

  • billing for items or services not rendered
  • unbundling 
  • providing medically unnecessary services 
  • billing for discharge in lieu of transfer 
  • upcoding
  • patients’ freedom of choice 
  • "DRG creep" 
  • credit balances - failure to refund 
  • outpatient services rendered in connection with inpatient stays
  • hospital incentives that violate anti-kickback statute or other similar federal or state statute or regulation 
  • teaching physician and resident requirements for teaching hospitals
  • financial arrangements between hospitals and hospital-based physicians
  • patient dumping
  • joint ventures
  • duplicate billing
  • Stark physician self-referral law 
  • false cost reports
  • knowing failure to provide covered services/necessary care to HMO members 

The Compliance Guidance further discusses the importance of hospitals’ designation of a Compliance Officer and Compliance Committee, conducting effective training and education programs, access to the compliance officer and the need to enforce standards through well-publicized disciplinary guidelines. The Compliance Guidance discusses appropriate responses to detected offenses and developing corrective action initiatives, including such steps as a referral to criminal and/or civil law enforcement authorities, a corrective action plan, a report to the Government and submission of any overpayments, if applicable. Hospitals should seek advice from legal counsel both as to the legal implications of having a compliance plan, but especially as to the legal consequences of investigating and reporting possible non-compliance.

Anyone considering implementing a compliance program should read the Compliance Guidance.

Additional information?  Please contact Connie Baker at (410) 244-7535 or CHBaker@venable.com.