The Centers for Medicare and Medicaid Services (CMS) continues to focus detection and enforcement efforts on Fraud, Waste and Abuse by taking aim in 2016 for a variety of CMS priorities. CMS continues to utilize data analytics and algorithms in “addressing the full spectrum of program integrity issues, in taking swift administrative actions, and in the performance of audits, investigations and payment oversight”. Healthcare organizations must remain diligent in their efforts to prevent Fraud, Waste and Abuses through education and compliance oversight programs.
In 2015, the Office of the Inspector General (OIG) reported recovery of $3 billion in audit receivables, and $2.22 billion in investigative receivables, which include about $286.6 million in the States’ shares of Medicaid restitution. The OIG reported exclusions of 4,112 individuals and entities from participation in Federal health care programs; 925 criminal actions against individuals or entities that engaged in HHS programs crimes; and 682 civil actions, which include false claims and unjust-enrichment lawsuits filed in Federal district court, CMP settlements, and administrative recoveries related to provider self-disclosures. (OIG 2016 Work Plan)
Healthcare delivery is evolving and the patient payment landscape is shifting. Population health management, Accountable Care Organizations, Hospital Value Based Purchasing programs, and the impact of the Affordable Care Act is blurring the compliance lines between physicians, hospitals, ambulatory surgical centers, and post-acute care. There are a number of upcoming CMS Advisory Briefs and Exceptions that is generating clarifications by CMS for Medicare Shared Savings Programs, Physician self-referrals, Gainsharing, and Safe Harbor exceptions. Medtrainer will continue adding learning content in short video-briefs entitled, CMS Compliance+ 2016™.
Steve Gallion has been providing healthcare related compliance consulting and services to the industry for over 10 years. He has had multiple companies from IT Security Compliance and Healthcare Waste Management to Regulatory Training and Compliance. He is an expert in many areas of healthcare compliance including OSHA, HIPAA, DOT, Billing and Accreditation. You can learn more about Steve and his company at http://www.medtrainer.com