OCTA 2040: FIELDWORK SEMINAR

CONSENSUS DOCUMENT ON COMPLIANCE REPORTING:

FRAUD &ABUSE

OTA has collaborated with the National Association for the Support of Long Term Care (NASL), the American Speech-Language-Hearing Association (ASHA), and the American Physical Therapy Association (APTA), to create a consensus document on Medicare compliance. PDF of the document here

The information below provides a pathway for clinicians who have questions about inconsistencies between their employer’s and Medicare’s policies, including recommended steps and resources.

COMPLIANCE REPORTING

Compliance is an organization’s adherence to laws, regulations, and policies applicable to its operations. Violations may result in punitive action, including the imposition of fines and/or criminal charges. Clinicians have a responsibility to adhere not only to their profession’s clinical and ethical standards, but all applicable laws, regulations and policies.

WHAT ARE CORPORATE COMPLIANCE PROGRAMS?

A compliance program integrates health care federal and state regulations, laws and professional standards and company standards into a common framework and provides a means for confidentially reporting concerns. An effective corporate compliance program helps ensure that clinicians and managers are conducting clinical activities and business operations ethically, legally, and with a high level of integrity. A successful compliance program also helps develop a culture of accountability and shared responsibility within an organization, facility, or company. A compliance program may be developed and carried out by the internal staff of the organization or may be contracted to an external entity. In both instances, the rules governing confidentiality of reporting and protections are the same.

Compliance officers function as an independent and objective body that is responsible for developing and implementing the compliance program as well as reviewing and evaluating compliance issues/concerns within the organization. Specifically, compliance officers carry out the following responsibilities:

Serve as the primary point of contact for all compliance concerns
Direct compliance issues to appropriate resources for investigation and resolution
Represent an internal resource with whom concerned parties may communicate
Facilitate requests from external entities on behalf of the organization in the case of denials, medical review, and investigations related to fraud, waste, and abuse
Have a duty to report violations to duly authorized enforcement agencies as appropriate and/or required by law
Are legally bound to maintain confidentiality of those reporting violations and to ensure those who report violations not subject to retribution.
In instances where confidentiality has been breached or a retaliatory measure has occurred as a result of information shared with the compliance officer, the situation can be reported to the Office of the Inspector General (OIG). See the contact information at the end of this document.

CONFIDENTIALITY vs. ANONYMITY

Clinicians are often confused by the terms confidential and anonymous—particularly in regard to which reporting method provides the most protection when reporting waste, fraud, and abuse.

Confidential reporting identifies the reporter to the compliance officer and transfers legal protection to the reporter. When reporting compliance issues to a designated compliance officer, confidentiality provides the best protection and is accomplished by making the report official rather than attempting to report without disclosing your identity.

Anonymity is the concept of cloaking the identification of the reporter. Anonymity can be hard to maintain and does not allow protections under the applicable federal and state whistle-blower laws if the identity of the reporter is discovered.

RECOMMENDED STEPS FOR REPORTING

Immediately stop engaging in any activity that you believe to be a compliance violation. Discuss concerns and questions with your immediate supervisor. Although concerns are best addressed directly, remember that only compliance officers are legally bound to ensure confidentiality and whistle blower protections.

Contact your facility and/or corporate compliance officer or hotline. Go to the compliance officer for your direct employer if you are not employed by the facility where you work. If they do not respond satisfactorily, you can go to your facility compliance officer, as well.

If you are unable to satisfactorily resolve the issue through the available internal channels:

For Medicare and Medicaid compliance issues, report your concerns to the Department of Health and Human Services (HHS), Office of Inspector General (OIG).

For issues related to state regulations, consider reporting your concerns to your state ombudsman programs and/or your state’s Office of the Attorney General.

If you have concerns about your liability or protections, seek professional legal counsel.

Contact your national professional association (American Occupational Therapy Association [AOTA], American Physical Therapy Association [APTA], and American Speech-Language-Hearing Association [ASHA]) for guidance if you have questions.

RESOURCES

Department of Health and Human Services (HHS), Office of Inspector General (OIG). The OIG is responsible for fraud and abuse prevention, detection, and reporting.

OIG Website

OIG Spotlight Articles

OIG Report Fraud Brochure (pdf)

Stop Medicare Fraud

OIG Compliance Website and Education Materials

OIG National Hotline and Address

(800) HHS-TIPS: (800) 447-8477 TTY: (800) 377-4950

Fax: (800) 223-8164

U.S. Dept. of Health and Human Services

ATTN: HOTLINE

P.O. Box 23489

Washington, DC 20026