Medicare Compliance & Reimbursement
Get Ready for an Overhaul of OIG’s Compliance Guidance
Hint: MA plans are first on the federal watchdog’s update list. With most federal healthcare compliance, as soon as you figure out the requirements, the feds change the rules. And a recent HHS Office of Inspector (OIG) notice indicates more of the same. OIG plans to rework its compliance program guidances, which likely means more work for you, experts predict. Old way: The first compliance program guidance (CPG) that OIG offered was for hospitals in February 1998. Six months later, the agency followed that up with guidance for home health agencies and clinical labs — and subsequently rolled out CPGs for a total of 11 different provider types with the last one issued for drug companies in 2003. The OIG issued CPGs for individual providers and small group practices on Oct. 5, 2000. Issuing the guidance documents marked “a major initiative to engage the private health care community in preventing the submission of erroneous claims and in combating fraud and abuse in Federal health care programs through voluntary compliance efforts,” the OIG says in an April 25 Federal Register notice about the revamp. “CPGs have served as an important and valuable OIG resource for the health care compliance community and industry stakeholders over the last 25 years.” New way: “OIG has carefully considered ways to improve and update existing CPGs and to deliver new CPGs,” the watchdog agency says. “In modernizing OIG’s CPGs, our goal is to produce useful, informative resources — as timely as possible — to help advance the industry’s voluntary compliance efforts in preventing fraud, waste, and abuse in the health care system.” Specifically, the OIG plans to develop a new format — one “General CPG (GCPG) that applies to all individuals and entities involved in the health care industry” and multiple “industry-specific CPGs (ICPGs) for different types of providers, suppliers, and other participants … relating to Federal health care programs,” according to the notice. The General CPG “will address topics such as: federal fraud and abuse laws, compliance program basics, operating effective compliance programs, and OIG processes and resources,” the agency explains. “We anticipate updating the GCPG as changes in compliance practices or legal requirements warrant.” Timeline 1: “OIG plans to publish the GCPG by the end of calendar year 2023,” it estimates. The industry-specific CPGs “will be tailored to fraud and abuse risk areas for each industry subsector and will address compliance measures that the industry subsector participants can take to reduce these risks,” the OIG elaborates. “ICPGs are intended to be updated periodically to address newly identified risk areas and compliance measures and to ensure timely and meaningful guidance from OIG.” Timeline 2: “OIG expects to begin publishing ICPGs in calendar year 2024. Currently, OIG anticipates that the first two ICPGs will address Medicare Advantage and nursing facilities,” the notice reveals. The new CPGs “will give us an idea of OIG’s current concerns,” predicts attorney Robert Markette Jr. with Hall Render in Indianapolis. Time is of the essence under the new structure. This “largely … administrative change … allows OIG to make adjustments to the CPGs more frequently,” explains attorney Matthew Wolfe with Baker, Donelson, Bearman, Caldwell & Berkowitz in Raleigh, North Carolina. “We saw a similar action with the Work Plan, which allows OIG to evolve its enforcement priorities more quickly,” Wolfe says. While Wolfe doesn’t anticipate any substantive changes initially, he does “anticipate that OIG will make updates more frequently,” he says. That means “providers will need to remain vigilant for more frequent changes,” he adds. Changes to CPGs may be a little harder to follow, as the OIG takes the notice of them into subregulatory channels. “When the new GCPG and ICPGs, along with any updates to these documents, are published on OIG’s website, OIG will notify the public using our public listserv and other communications platforms,” the agency says in the notice. Resource: Review the notice at www.govinfo.gov/content/pkg/ FR-2023-04-25/pdf/2023-08326.pdf.
Medicare Compliance & Reimbursement
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