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“Houston, We Have a Problem…”

“Houston, We Have a Problem…”. Responding to Billing Mistakes and Government Investigations. Protecting your Providers. “Houston, We Have a Problem”. Step One: Panic Step Two: Breathe Step Three: Follow the Plan. Self Discovery of a Billing or Coding Issue. How is an issue discovered?

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“Houston, We Have a Problem…”

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  1. “Houston, We Have a Problem…” Responding to Billing Mistakes and Government Investigations

  2. Protecting your Providers

  3. “Houston, We Have a Problem” • Step One: Panic • Step Two: Breathe • Step Three: Follow the Plan

  4. Self Discovery of a Billing or Coding Issue • How is an issue discovered? • corporate compliance review • internal audit • external audit • patient complaint • employee complaint • competitor complaint • water cooler, elevator and cafeteria

  5. Identifying the Issue • Initial assessment of scope and severity • coding error (systems issue) • one or more providers • willful or just ignorant • pattern of concern • past behavior • policy-based issue • one or more payors • federal health care programs

  6. Initial Internal Investigation • Compliance office and/or compliance committee • Identifying issues where outside counsel should be leading the investigation • Containment plan • any immediate action required • ongoing/future behavior changes • risk management needs

  7. Outside Counsel – Internal Investigation

  8. Outside Counsel • Internal lines of authority and communication • Attorney-client privilege • Leading the investigation • Investigation plan • Report/plan to the Board and/or Compliance Committee • Litigation hold • Document review • Witness interviews • Risk assessment • Action plan recommendations • Policy/procedure development

  9. Timing of Investigation Overpayments Must be reported & returned within 60 days of the date identified or the date when the corresponding cost report is due, whichever is later Has there been an Overpayment?

  10. False Claim Act - Risks Knowingly conceals or improperly avoids an obligation to pay money

  11. Refunds and Repayments to the Carrier • When to Report • When is overpayment identified • What to Report and Refund • How far back in time? • Each claim? • Extrapolation? • Refund • Carrier requirements • Self Disclosure • Risk Analysis

  12. The Mission of the OIG To protect the integrity of HHS programs and operations and the wellbeing of beneficiaries by: * detecting and preventing fraud, waste, and abuse; * identifying opportunities to improve program economy, efficiency, and effectiveness; and * holding accountable those who do not meet program requirements or who violate Federal laws.

  13. Target of the Investigation • Step One: Panic • Step Two: Breathe • Step Three: Follow the Plan

  14. What is the Plan? • Corporate Compliance Plan should include response to on-site investigators • Train staff and managers how to respond • Scripting • Response Team Notification • Administration • Legal Counsel • Legal counsel action plan

  15. Legal Counsel Action Plan • Establishing rapport with investigators • Promoting a spirit of cooperation • Notice and planning with administration • Litigation holds • Establishing lines of authority • Internal investigation scope • Same issues • Related issues • Rumors • Conducting internal investigation • Documents • Witnesses • Experts

  16. Working with the Department of Justice • Attitude, attitude, attitude • Educating the government • Clinical issues • Operational issues • Providing documents • Providing witnesses • Providing position statements • Settlement options

  17. Responding to Requests for Discovery • Informal requests • Witness interviews • Civil Investigative Demand • Subpoenas • Peer Review Protections • Letters of Assurance

  18. Additional Risks and Items for Consideration • Criminal behavior? • Obstruction of justice? • Medical malpractice claims? • Fiduciary duties? • Public relations • Press release • Insurance coverage

  19. Discussion and questions

  20. Laura D. Seng, RN, JD, PartnerBarnes & Thornburg LLP100 North Michigan, Suite 700South Bend, Indiana 46601(574) 237-1129Laura.Seng@btlaw.com

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