Under the FCA, any individual has the right to sue an entity they believe to have committed fraud against the government–and to recover funds on their behalf.
Risk Management Series: Individual Accountability in Corporate Wrongdoing
Late last year, former US Deputy Attorney General Rod J. Rosenstein announced the Department of Justice’s (DOJ) intent to focus on individual wrongdoers in corporate investigations.
Several factors play a role in shifting benchmarks from year to year. By understanding why these benchmarks change from year to year, you can adapt your compliance plan to prepare for change.
Encompass Health Settles False Claims Allegations with DOJ
One way hospitals and health systems can mitigate compliance risk is to promote organization-wide compliance policies and procedures with buy-in from executives, administrators, and physicians.
As part of our 10th anniversary series, we’re taking a closer look at the key factors that influence physician payment rates based on our analysis of our 2019 benchmarks.
Our 2019 report highlights the growing significance of physician contracts as a major component of hospital spending, with particular growth in payment for hospital-based physician services such as hospitalists, intensivists and laborists.
Overpayments can be hidden—particularly when there is “stacking” of physician agreements that results in total payments to an individual or group exceeding reasonable levels.
“Outdated policies from HHS mean not only less than desirable results for taxpayers and for beneficiaries of our programs, but often for patients and payers in the private market as well. The role played in paying for services by our own policies at HHS is dominant, which means where we aren’t innovating, we hold things back.” – Deputy HHS Secretary Eric Hargan
The Department of Health and Human Services announced a “regulatory sprint to coordinated care” in June 2018, a new initiative to remove regulatory barriers that impede the transition to a coordinated, value-based health delivery system.
Selecting a Valuation Firm – Identifying a Good Cultural Fit
In order to ensure that you are getting the quality opinions you require, you should be working with experts who understand your organization’s unique needs.
The purpose of a CIA is to strengthen an organization’s compliance program with policies and procedures approved by the government. The OIG must have confidence that the organization is taking steps to prevent new violations.
Commercial Reasonableness: Testing and Documentation
Many recent settlements for Stark and Anti-Kickback violations stem from failure to meet commercial reasonableness standards or from lack of documentation of an agreement’s commercial reasonableness.
How Children’s Hospitals Differ from General Acute Care Facilities
Pediatric facilities understandably have a specific set of patients and, as a result, they have different physician contracting needs than most hospitals.
While cases where physician compensation benchmarks change rapidly from year to year certainly garner more attention, it can be insightful to examine when the opposite is true as well.
Mistakes to Avoid in Hospital-Based Physician Contracts
While these arrangements benefit patients, physicians and healthcare organizations, they are usually complex and require careful attention to payment and service requirements.
Understanding how outliers affect market data and what to do if your contract falls outside market ranges is an important aspect of a physician contracting compliance program.
Alternatives to Per Diem Payments for Call Coverage
Over the past decade, spending for physician expenditures as a percent of total hospital operating expenditures has grown over 40% according to OSHPD data. Costs will escalate when a hospital starts to compensate one specialty, which will create a domino effect with others.
Contracting for Pediatric Services? Read This First.
Many community healthcare organizations address this need by contracting with a children’s hospital or academic medical center. Several specialty physician companies also provide pediatric physician services.
Preparing for a physician contract negotiation? As you’ve likely discovered, these conversations take time and effort, and often go differently than anticipated.
The OIG published a Fraud Alert, which warns physicians that they could take on personal risk under the Anti-Kickback Statute for noncompliant compensation arrangements.
Five Tips for Making Physician Contracting More Efficient
MD Ranger subscribers are constructing order out of the complex processes of contract organization, negotiation, and approvals by creating a more structured, efficient, and informed system. Physician contracting and documenting FMV doesn’t have to be an expensive headache.
While making significant changes or implementing new policies requires time and slow approval processes, there are some tactical improvements you can make today.
Catching Hidden Overpayments in Physician Agreements: Stacking Risks
Risks for overpayments are things like paying above FMV, or paying for too many hours per administrative deal are straightforward to discover with careful review and analysis of contracts.
Operational and Financial Management of Physician Agreements
We recently spoke with Gail Peace, CEO of Ludi, about how hospitals are managing physician contracts from both an operational and finacnial perspective
In September 2015, Sally Yates, an attorney for the DOJ wrote a memo stating that individuals were to be held accountable in corporate wrongdoing cases.
No Joke: Personal Liability in a Post-Yates Memo Era
In September 2015, we first heard of the Yates memo and were warned that the DOJ was going to take individual accountability in corporate wrongdoing seriously. We have seen fines against individual physicians, but now we know hospital executives can no longer ignore the risks.
CIAs are fairly uniform; however, most include specific requirements tailored to the violation(s) that led to the settlement. CIAs typically run 3-5 years.
Prepare for and Document the Negotiation Conversations
After building a case for why the organization needs the physician and role in question, prepare for the negotiation conversation. Anticipate where there will be pushback and where compromises can occur. Then, be sure to organize and document everything, this will save you a headache at a later date.
Key Stark Law Developments: What Every Compliance Officer Needs to Know
In cases of compliance infractions, courts consider all the relevant facts in including commercial reasonableness of an arrangement and whether or not an organization made a good faith effort to comply.
HCCA 2016: DOJ and OIG Focus on Physician Compensation
A theme throughout the Compliance Institute was that shopping for FMV valuations conflicts with FMV being based on an “independent third party opinion”.
Each year, Dan Levinson provides HCCA’s attendees with a glimpse into what the OIG has occurred within the OIG recently and what they will be focusing on over the next year.
Stark Law has recently hit the healthcare spotlight and is often framed as fraud. Though fraudulent arrangements do exist, Stark also leaves no margin for simple error due to structure as an exception statute.
HCCA 2016: Communicating with Regulators and Enforcement: Avoiding Pitfalls
The Monday afternoon Communicating with Regulators and Enforcement: Avoiding Pitfalls session gave a glimpse into the mind of regulators and prosecutors.
HCCA 2016: The Stark Trifecta: How Legal, Compliance, and Outside Counsel Work Together on Stark Compliance
Our speakers pulled together a fun, scripted case study to demonstrate how internal legal, compliance, and outside counsel can successfully work together to handle Stark-related risks and issues.
If you are overwhelmed by physician contracting compliance, or are unsure what elements are essential in a good compliance process, a great way to create structure is to review requirements outlined in recent corporate integrity agreements (CIAs).
Do You Have Guidelines for Handling Exceptional Physician Agreements?
When your organization determines it must compensate a physician above your standard for fair market value, create a standardized process for reviewing such exceptional contracts.
The OIG actions of the past two years illustrate the risks of noncompliant contracts to healthcare organizations and individuals who do not have a comprehensive compliance program for review and documentation of physician contracts.
FMV is not the end of the road, you still have to enforce the contracts
When our subscribers ask about physician contract compliance best practices, we caution them to be sure that the annual payment, the hourly rate, and the hours of service are compliant, and that contract performance and payments are tracked.
Recent actions by the OIG make it clear that they are investigating physicians as well as hospitals when they suspect a physician contract violates Stark, Anti-Kickback, or False Claims Act regulations.
Most physician payment rates fall within a reasonable market range. But in some cases, a payment rate may be well beyond the norm. These unusual payment rates, which can sometimes impact benchmark calculations, are outliers.
