June 2018 Takeaways
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Medicare Part A & Part B:
Audits and auditors
by R. Ross Burris, III and Lidia Niecko-Najjum
» The federal government estimates that for the Fiscal
Reporting Year (FY) 2016, 11% or $41.1 billion of all
Medicare Fee-for-Service (FFS) claim payments were
» The results of CMS Integrity Program, intended to curb
fraud and abuse, have been mixed, and now appeals
of claims denials are severely backlogged.
» Understanding the CMS Integrity Program and its key
auditors, the auditing process and, most importantly,
the appeals process may help you avoid the backlog.
» The appeals process starts at the very first request for
» Having a process in place and strategies for
addressing audits can help you win an appeal.
Post-MACRA gainsharing OIG advisory
opinion focuses on patient-centered care
by Diana M. Fratto, Esq., Paulina M. Grabczak,
Esq., and Gary W. Herschman, Esq. (page 30)
» Providing patients with medically necessary care,
determined on a patient-by-patient basis, is a primary
focus in structuring gainsharing arrangements.
» Any proposed recommendations for physician
behavior modifications must be medically appropriate
and consistent with prevailing clinical standards.
» Ongoing monitoring and oversight of gainsharing
arrangements is essential for transparency and
» Gainsharing arrangements should include a
mechanism for ensuring that payments are tied
to actual, verifiable cost savings achieved, and
physicians are not rewarded for prior achievements.
» Quality-of-care thresholds should be satisfied before
providing physicians with any compensation relating
to cost savings.
Designing a coding compliance plan
by Ghazal Irfan (page 38)
» Updating your coding compliance program will help
avoid external investigations.
» OIG’s Work Plan routinely identifies compliance high-risk areas that are under scrutiny.
» Recovery Audit Contractors will deny claims that lack
supporting evidence for “medical necessity.”
» PEPPER reports are a valuable tool for finding high-risk payment areas and outlier statuses.
» To stay compliant, transitioning towards quality
initiatives is a must!
Now arrived: Procurement changes to
OMB Uniform Guidance
by Brian Santo (page 44)
» The new Uniform Guidance procurement standards
are now in effect, and certain recipients of federal
awards now have a new set of procurement
regulations with which to comply.
» The Uniform Guidance is applicable to state and
local governments, American Indian tribes, higher
education institutions, and not-for-profit organizations
for all federal awards or funding increments to existing
awards made on or after December 26, 2014.
» The five approved procurement methodologies are
procurement by micro-purchases, small purchase
procedures, sealed bids, competitive proposals, and
» As always, documentation is key to ensuring evidence
of good faith compliance with the Uniform Guidance.
» Many organizations, especially non-profits, have
limited resources and should consider seeking outside
assistance to identify compliance gaps and conform
their internal processes and procedures to comply
with the new standards.
Improving outcomes of Compliance
Program Effectiveness audits
by Tonya Teschendorf (page 50)
» The Compliance Program Effectiveness (CPE) audit is
considered to be the most rigorous and demanding
audit conducted by CMS.
» Past findings of CPE audit outcomes are a good
indication of the deficiencies that CMS will be looking
for in the future.
» Plan sponsors who have not been audited in the
last three to five years tend to struggle more with
» Plans can improve the outcomes of CPE audits
by concentrating on the Top 5 issues consistently
uncovered since 2011.
» The importance of documentation and communication
cannot be overemphasized.
Federal guidance for hospice providers:
A year in review
by Bill Musick (page 56)
» Hospices must keep abreast of activity by multiple
» Drop the notion that there’s such thing as an
“acceptable” error rate.
» Hospices should examine the relationship between
the compliance officer and the board.
» Risk areas include clinical documentation, physician
arrangements, and employee oversight.
» Communication with contracted organizations is
Compliance with attestation
requirements: Tips for FDR
by Bethany A. Corbin (page 60)
» First tier, downstream, or related entities (FDRs) must
build compliance frameworks to satisfy attestation
» Standards of conduct and effective communication are
crucial for compliance.
» Relevant documents must be retained for ten years.
» Manage risks through a risk assessment and annual
» Report the use of offshore entities.
Healthcare system “rulebook”
by Miriam R. Miller (page 67)
» Policies and procedures in a healthcare system set the
tone for the system.
» Healthcare professionals must be up to date on
changes in the regulatory environment in order to
have an effective policy and procedure review system.
» A regular review cycle for policies and procedures
helps find issues that were not previously identified
and ensures the content of the documents is
up to date.
» It is important to have a process for notifying and
educating employees on policy updates that affect
» Compliance departments can set a good example for
the healthcare system with their policy management
Compliance risk and the legalization
by Dan Coney (page 70)
» The business of compliance is an exercise in
identifying risks; state legalization of marijuana is a
» Participation in federal healthcare programs requires
healthcare providers to comply with federal law.
» Federal law classifies marijuana as a Schedule I
controlled substance, meaning it has no medical
value, and the FDA has not approved marijuana for
any medical use.
» Legalization measures have produced further risk in
that cannabis potency has greatly increased and there
is no consistency with the drug.
» Compliance professionals should recognize that
increased scrutiny could accompany recent DOJ
decisions to enforce federal drug laws for marijuana.
The ethics of taking and giving gifts
by Paul P. Jesep (page 73)
» The code of conduct should be clear about if and when
a gift can be given or accepted.
» A broad policy that prohibits gift giving may be best,
with limited exceptions carved out.
» Apply common sense to all situations. As a courtesy,
you may have to accept or give a gift.
» Perception is reality. Even a token gift can cause a
problem for a person’s or organization’s reputation.
» State and federal laws don’t cover every possibility
where an individual can fall victim to improper
influence. Go above and beyond what the law expects.