Cooperating for better care.

False Claims Act

Tag Archives

Holding hospital boards accountable for institutional culture

November 2, 2017by Robert Whitcomb in Uncategorized tagged , ,

 

Healthcare analyst and consultant Paul Keckley, Ph.D. has looked at how hospital boards  should be held accountable for their institutions’ culture.

He noted:

“On Wednesday, Oct. 4, the National Association of Corporate Directors released a report from its 34-member commission outlining 10 recommendations that would encourage boards to be more proactive in attending to corporate culture. They include the formal measurement of culture, the inclusion of culture considerations in performance reviews of top managers, changes to incentives in short- and long-term compensation and others. Their bottom line is this: Boards must understand how an organization achieves results, not just the results themselves. ”

He writes about:

“Board education: …. Nonprofit boards underinvest in board education and many are lax in evaluating their boards. Complex issues like private inurement, the False Claims Act, HIPAA and many more require more than casual understanding by trustees.”

“Culture monitoring processes: Hospital boards must create a formal process for monitoring the culture in their hospitals. Most hospitals conduct employee surveys and share the results with the board. Many of these include comparisons to other organizations and best practice recommendations. But in the future, boards must go deeper. The work climate in most hospitals is stressful. The workforce is expected to do more with less and alter work habits as clinical innovations and payment schemes force change. Boards must examine the mechanisms whereby the workforce is managed, promotions awarded, recognition and compensation given.”

To read his whole commentary, please hit this link.

 

 

Medicare overpayments-retention case gets attention

August 24, 2016by Robert Whitcomb in Uncategorized tagged

Mount_Sinai_Health_System_Logo

That three hospitals within  the Mount Sinai Health System, in New York, must pay  the Feds nearly $3 million to settle a whistle-blower suit alleging that they held onto Medicare and Medicaid overpayments beyond the 60-day repayment window may put healthcare systems across America on notice.

Mount Sinai  will  pay $2.95 million rather than go to trial over $844,000 in retained Medicaid overpayments. After a trial, the  big system could have faced treble damages as well as $4.9 million in False Claims Act penalties for the 444 payments in question.

Mount Sinai had asked a federal court in 2014 to throw out the case.

Modern Healthcare reported that a New York state comptroller audit in September 2010 “alerted the hospitals to potential overpayments caused by a computer glitch as well as a whistle-blower email in February 2011. But they didn’t refund all of the overpayments until March 2013, say federal and state prosecutors, well beyond the allotted window to return overpayments to the government.”

The  Fraud Enforcement Recovery Act and a 2010 provision in the Affordable Care Act give Medicare and Medicaid providers  60 days to repay overpayments from the time they are identified. After that,  the retained overpayments are subject to the False Claims Act and additional potential liabilities. Hospitals have strongly opposed these rules.

To read the full article on this, please hit this link.

 

 

 

 

 

 

The Supremes’ busy healthcare year

July 5, 2016by Robert Whitcomb in Uncategorized tagged ,

scotusseal

Herewith a very useful review of healthcare-sector-related decisions by the U.S. Supreme Court in its just-completed season.

Among the cases: abortion/contraception; data access; patents, the False Claims Act and unions.

To read the Modern Healthcare article, please hit this link.

CMS orders physicians to hunt down overpayments

February 12, 2016by Robert Whitcomb in Uncategorized tagged , , , , , , , , ,

foxhunt

Medscape reports that new rules from CMS say that “physicians must not only return Medicare overpayments within 60 days of identifying them but also actively look for overpayment through self-audits and other forms of research….”

“If a physician fails to hand back overpayments within 60 days, he or she risks getting sued by the government under the False Claims Act (FCA).”

Many physicians, already drowning in paperwork, will not be pleased by this latest CMS mandate.

“This requirement would be extremely burdensome for physicians as it would impose a boundless duty to troll medical records in search of innumerable vulnerabilities,” the American Medical Association and dozens of other medical societies wrote CMS in 2012.

“CMS did not cut organized medicine any slack in its final regulations, but instead said what physicians did not want to hear. The agency also warned that some healthcare providers might avoid self-scrutiny for the sake of not discovering money they would have to return,” the publication reported.

“We disagree that this rule creates a requirement for any formal compliance plan or audit strategy,” CMS said. “Rather, it requires that providers and suppliers maintain responsible business practices and conduct a reasonably diligent inquiry when information indicates that an overpayment may exist.”

Wanda Filer, M.D., president of the American Academy of Family Physicians, one of the signatories to the 2012 letter to CMS, told Medscape that she hopes the agency will “interpret ‘clear duty’ very gently,” lest, as the publications put it, “physicians find themselves with more administrative work that reduces face time with patients”

“Patients have one clear duty, and that’s taking care of patients,” Dr Filer told Medscape.  “CMS has a clear duty to protect the Medicare trust fund. How we strike the balance…will be the art of this.”

Attention boards: Four big things to remember

February 9, 2016by Robert Whitcomb in Uncategorized tagged , , , , , , ,

 

This article in Hospitals & Health Networks looks at four areas that hospital boards must pay more attention t0 these days:

1. “Physician relationships and practice patterns: Hospitals increasingly are accountable for physician behavior as a result of the stiffening of Stark anti-kickback rules, widening provisions of the False Claims Act, exposure resulting from the Physician Sunshine Act and Medicare Physician Database, provisions in the Affordable Care Act that heighten scrutiny for physician business dealings and the trend toward physician employment.”

2. “Partnerships and affiliations: Every hospital regardless of size is attempting to reduce its operating costs and evaluating its future. These efforts invariably involve consideration of formal relationships with other hospitals and formal relationships with private insurers, outsourcing partners, technology suppliers and others. Hospital boards must know the details of each deal, how debt covenants and operations are impacted, and where there’s financial or reputational risk if the marriage hits the rocks.”

3.  “Performance risk: Historically, bread and butter operational functions like purchasing, business office operations and clinical documentation have been a key focus for hospital compliance efforts and rightly so. They’re complicated and costly, and where ethical or legal lines are crossed, whistleblowers are increasingly watchful. Adding complexity, the shifting of incentives from fee for service to value-based payments, is ripe for performance risk….”

4. “Reputation risks: ...How a {hospital’s} reputation is measured and its accessibility to outside parties including lenders and the community is increasingly more sophisticated. Achieving recognition on credible report cards, like those offered by U.S. News & World Report, Truven, Leapfrog Group and others is an important start, because their methodologies are credible. But access to data about a hospital’s clinical, operational and financial performance is expanding exponentially through social media and proprietary vendors. …”

 

S.C. hospital, deep in legal woes, seeks suitor

February 6, 2015by Robert Whitcomb in Uncategorized tagged ,

 

Modern Healthcare reports that Tuomey Healthcare System, in Sumter, S.C., seeks a partner to get through its financial woes, part of which stem from a i10-year legal battle over alleged illegal payments to physicians.

“Two years ago a federal judge ordered the not-for-profit provider to pay the government $237 million, a sum that exceeds its annual revenue,” the publication reported.

”A federal jury concluded in 2013 that the hospital violated the False Claims Act by submitting tens of thousands of illegal claims to Medicare. The jury found that Tuomey paid doctors in ways that rewarded them financially for referring patients to the hospital …causing the Medicare claims to be tainted.”

Federal investigators  can’t keep up with the temptations to get Medicare money through dubious means.


Contact Info

info@cmg625.com

(617) 230-4965

Wellesley, Mass