Keeping the OIG at Bay

AMARILLO, Texas — Most HME providers know the term
“corporate compliance,” but many do not appreciate what a proper
compliance program can do for an organization, according to Clay
Stribling. Done right, an effective program can prevent problems
before they happen, or allow companies to respond quickly and
address concerns before the FBI or OIG comes calling.

Stribling, president of HC Comply, does nothing but focus on how
HME suppliers can implement and maintain effective compliance
programs. Even if compliance were not mandatory, the Amarillo,
Texas-based health care attorney and consultant believes the
discipline instilled through a good program would lead to a
healthier bottom line.

Do providers have a choice when it comes to compliance? The
answer is a bit more nebulous than you might think.

“It is kind of an unsettled question at this point,” said
Stribling. “As a part of accreditation, providers are required to
have policies and procedures that address fraud, waste and abuse,
and they are required to have someone in their organization who
coordinates those efforts. In my mind, that means compliance
policies, because those are policies that are designed to reduce
fraud.”

The other part of the picture concerns health reform, also known
as the Affordable Care Act (ACA), which is going to
require all entities billing Medicare (except physicians)
to have corporate compliance programs. There is currently no date
for that deadline, but Stribling heard from a former CMS official
that a timeline for compliance provisions would likely appear by
the end of the year.

While the exact nature of the ACA’s compliance requirement is
unknown, Stribling advises providers to work on a compliance
program in advance, since all manner of payers can and will ask to
look at charts, operations and day-to-day business. “The best way
to prevent them from finding something inappropriate is to be
conducting that internal review continuously in your own business,”
counseled Stribling. “If someone comes in and says, ‘We want to
look at your CPAP files,’ you should not be panicking. You should
be saying, ‘That is great because I audit my CPAP files every
single quarter, and I know exactly what is in there.’”

Implementing a compliance program, taking an internal look at
charts and operations and auditing marketing functions accomplishes
several crucial things, Stribling said. “You know what they are
going to find when you turn [your files] over, and when you find an
error, you launch a training program and a corrective action for
anything that you found that is a problem. Even if they do come and
look at charts and find problems from three years ago, you can
… show that you have a process in place for identifying and
correcting these, and that can go a long way with any of the
contractors in helping diffuse concerns about your company.”

As a result, he said, “compliance programs can save you a good
bit of money.”

One thing is certain: The government will not stop its mission
to audit and oversee the HME industry. One reason is that the
effort often bears fruit.

“The fascinating thing about health care fraud investigations
from the federal government standpoint is it is one of the few
things the federal government does that is unbelievably
cost-effective, and even profitable for the government,” said
Stribling.

“The data that I love to quote is several years old now, but in
2002 for every dollar the federal government spent of health care
fraud enforcement, they got $28 in return. Recent numbers I have
seen in past years show that it is between $12 and $16 in return.
Still, it is something that the federal government spends money on
and gets more money back.”

Looking at the industry as a whole, Stribling said, “there are
plenty of bad players out there that make it an attractive
landscape for the federal government to investigate. I am not
trying to paint with a broad brush and say that this industry is
problematic, because I think that by and large the established
players in this market are committed to doing things the right way.
But, because there are players out there that are trying to get
into this industry, profit through fraud, and get out, the federal
government sees it as an industry that is ripe for enforcement.

“Companies need to be ready for scrutiny, even if they are doing
things the right way,” he continued. “The government is going to
come in and kick the tires, and you need to know before they get
there what they are going to find.”