June 2017 Takeaways
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Patient payment transactions:
A confluence of security and
by Ken Briggs (page 22)
» The patient payment transaction is an often
underestimated source of confusion and
» Breaches or weak safeguards in patient payment
systems can affect millions of individuals over a
short amount of time.
» Security requirements relating to patient payments
come from a variety of sources, including HIPAA and
» Network segmentation, encryption, and outsourcing
are attractive solutions to minimize liability for a
» A healthy compliance program will involve familiarity
with the applicable privacy and security obligations
as well as industry solutions to reduce exposure
Medicare appeals process: CMS
publishes final rule revising regulations
by Andrew B. Wachler and Jessica C. Forster
» Federal court ruling requires HHS to take action to
reduce the Medicare appeals backlog.
» Additional efforts to reduce the Medicare appeals
backlog are helping, but not completely relieving the
Medicare appeals backlog.
» The final rule implements changes that will improve
efficiencies throughout the Medicare appeals
process, but are insufficient in themselves to
respond the backlog.
» The final rule provides important regulatory
clarification to longstanding components to the
Medicare appeals process.
» The final rule will impact providers’ and suppliers’
strategic approaches to audits and appeals.
Reducing the risk of False Claims Act
qui tam actions
by Joan W. Feldman (page 38)
» All alleged false claim complaints should be
» Respond to the complaint in a timely manner.
» Develop a plan and timeline for the investigation.
» Keep complainant(s) informed and report results of
the investigation to them.
» Keep clear documentation as to the analysis and
The secret to effective compliance
training is engagement
by Gary. N. Jones (page 43)
» Effective training is the heart and soul of a good
» Engaging employees in a highly digital world
requires deliberate effort.
» Content is important, but delivery has a greater
impact on retention.
» Effective training isn’t about gimmicks or cartoons.
» With PowerPoint presentations, often less is more.
Surviving value-based healthcare with
by Annette Sullivan (page 48)
» The impact of revenue integrity on value-based
healthcare is often overlooked.
» Revenue integrity must be a formal, centralized
process that is constant and inclusive of all
departments and individuals that affect the
» The integrity of your data in 2017 will determine the
payments you receive and the penalties you incur
» Track and trend issues, determine the root causes,
and implement solutions to improve efficiencies.
» Develop an audit plan to reduce days in AR and
mitigate risks of claims denials.
Legal holds: Best practices for meeting
by Brian Santo (page 52)
» An organization may issue a legal hold to preserve
relevant documents in response to a complaint or
threat of litigation, to a subpoena, or upon notice of
a formal inquiry or investigation.
» An organization that fails a DCAA audit jeopardizes
its reputation and competitiveness within the
government contracting community.
» The Sedona Guidelines for Managing Information
& Records in the Electronic Age are an excellent
reference point for organizations seeking to develop
or improve their legal hold program.
» Logging the steps taken, key decision points, and
process milestones can demonstrate to the court
that the legal hold process was implemented
reasonably and in good faith.
» Overbroad legal holds increase the cost of data
storage, maintenance, and legal review and may
result in retaining “smoking gun” documents that
could have been legitimately deleted before or
between legal holds.
Should on-call independent
contractors be compensated more
than employed physicians?
by Bartt B. Warner (page 55)
» Physician on-call coverage arrangements are
subject to various laws and regulations.
» Understanding the underlying value drivers of
unrestricted call coverage is crucial.
» The fair market value (FMV) rate for independent
contractors is normally not the same as the FMV
rate for employed physicians.
» Understand the Stark Law and Anti-Kickback
Statute and review with internal legal counsel
» Seek an independent valuation firm to complete an
FMV opinion if there is any concern related to the
on-call coverage payments.
Top 10 federal audit findings
for implantable medical device
credits, Part 1
by Michael G. Calahan (page 59)
» The OIG has found certain areas of device credit
reporting to be lucrative for provider repayments
» Review the underlying principles of the device
» Key employees should be taught to recognize the
reportable device credit thresholds and how to
correctly apply the device credit calculations.
» The typical workflow process will involve
cross-departmental staff, but it generally works if
communication is good between departments.
» The top error found during federal audits is not
pursuing all of the available vendor credits for the
associated implantable device.
DOJ guidance: Focus on integrating
compliance and business operations
by Pamela Del Negro (page 65)
» The DOJ released sample questions it may
ask when evaluating the effectiveness of a
» The 100+ questions cover 11 topics that are
“important” for the DOJ.
» Topics addressed include third-party risks and
demonstrated commitment to compliance by senior
and middle managers.
» Many of the questions focus on how compliance
functions are integrated into business operations.
» The questions are a useful tool to evaluate a
compliance program and educate board members
and senior management on how a compliance
program is evaluated by the DOJ.