PWW’s Compliance Queen, Amanda Stark, was in Washington D.C. this week for the national Healthcare Enforcement Compliance Conference.  She heard from top officials at the Department of Justice (DOJ), the Office of Inspector General (OIG), and the CMS Deputy Director of Program Integrity along with many other government enforcement officials.  Here’s what we’ve learned:

• Data is the name of the game.  All areas of government enforcement are utilizing data to identify and investigate fraud.  You need to be looking at your data to see where you stand compared to others in the industry.  If you’re an outlier, be prepared to explain why.

• The DOJ cares about your compliance program.  If you’re investigated, the effectiveness of your compliance program will be a factor in how the investigation is resolved.  You’ll need to answer why your compliance program didn’t detect the problem at issue and what you’re doing to keep it from happening again.

• Compliance Officers need appropriate resources.  According to the government, this means the compliance officer is integrated throughout the agency, has a seat at the decision-making table and is not stretched too thin with other responsibilities.

• New guidance is coming.  The DOJ revealed it will release guidance by the end of this year talking about what organizations need to do during an investigation to receive “cooperation credit”.  Cooperating with investigators doesn’t mean you give up on your right to defend yourself!  But it does mean that you assist in the investigation, disclose problems you find and take remedial action to fix the issues.

• The OIG Work Plan is an inside look at its enforcement priorities.  As a reminder, ambulance is mentioned twice in the current Work Plan. The OIG is looking into over-billing at the ALS1- Emergency level and improper application of the Skilled Nursing Facility Consolidated Billing requirements.

• When you find a problem- disclose it! The OIG and DOJ both view disclosures, whether it’s voluntary refunds, utilizing the OIG Self-Disclosure Protocol or some other method, as an indicator of an effective compliance program.  In other words, the government doesn’t expect perfection- problems should be detected.  How the problems are handled sets those with effective compliance programs apart from those who don’t.  Of course, you can’t just disclose and keep doing the same thing.  You also need to fix the underlying issue.

• CMS wants to educate, not punish.  This is evidenced through new initiatives such as the Targeted Probe & Educate (TPE) audits.  If you are subject to a TPE audit or some other audit or education process from Medicare, you should be using those experiences to learn, make changes and improve.

All of these topics will be covered in-depth at abc360 in Las Vegas, St. Louis and Clearwater Beach this spring along with tips for handling an audit, surviving an enforcement action and improving your compliance program.