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What Can We Learn From OIG'S Fraud Risk Indicator?

Have you ever wondered how the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) determines future risk? As it turns out, the fraud risk indicator is OIG’s assessment of the future risk posed by persons who have allegedly engaged in civil healthcare fraud. And the numbers are impacted by the numbers of False Claims Act (FCA) settlements that fall on the risk assessment quarterly.

For the first quarter of Federal Year 2019, the following False Claims Act Settlements appeared on the Risk Spectrum:

 

 

This image tells us quite a bit about what categories OIG believes pose the highest risk.

 

  • Exclusion is the Highest Risk category. Parties that OIG determines present the highest risk of fraud will be excluded from Federal healthcare programs. Excluded entities are listed in the OIG’s Exclusions Database.
  • Heightened Scrutiny is a High-Risk category. Parties in this category are said to pose a significant risk to healthcare programs and beneficiaries. These parties require additional oversight; however, they refused to enter Corporate Integrity Agreements (CIAs) sufficient to protect Federal healthcare programs.\
  • CIAs make up the Medium Risk category. This includes healthcare providers who have signed CIAs with OIG to settle investigations involving Federal healthcare programs. As part of a CIA, a provider may agree to fulfill various obligations in exchange for continuing to participate in programs.
  • A Lower Risk Category is No Further Action. This means OIG concludes that parties present a relatively low risk to Federal healthcare programs. As a result, OIG is not seeking to exclude them from those programs or require a CIA. OIG's cases against these parties are closed without evaluating the effectiveness of any efforts the parties have made to ensure future compliance with Federal healthcare program requirements.
  • Finally, Self-Disclosure is a Low-Risk Category. In this category are parties who may disclose evidence of potential fraud related to Federal healthcare programs to OIG. OIG believes that doing so in good faith and cooperating with OIG's review and resolution process generally demonstrates that the party has an effective compliance program. OIG works to resolve such cases faster, for lower settlement amounts, and with a release from potential exclusion with no CIA or other requirements.

 

Important Takeaways

The OIG’s Fraud Risk Indicator helps the OIG to assess future risk and places each party to an FCA settlement into one of five categories. Healthcare organizations can be adequately prepared in the event of an inquiry from the OIG with an implemented compliance program in place.  To be prepared, activities such as performing exclusion list screening prior to hire or contracting and monthly thereafter, are a must.

If you have questions or if you need help implementing any compliance elements, we are happy to help. Contact us by phone: 855-427-0427 or by email at [email protected]

 

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