OIG Compliance: Civil Monetary Penalties

The OIG’s Civil Monetary Penalties target violations like false claims, with fines from $10,000 to $1 million. Watch the video for details!

Transcript:

So there are five federal laws that you need to be aware of as you put together your OIG compliance plan. Those are the False Claims Act, the Anti-Kickback Statute, the Self Referral Law, Exclusion Rules, and the last one that I want to talk about now is Civil Monetary Penalties for chiropractors. The Office of the Inspector General, which is part of the Department of Health and Human Services, has the authority to seek Civil Monetary Penalties or CMPs for a wide variety of conduct that could be considered either abusive or fraudulent. This includes things like getting paid for a service that is deemed to be medically unnecessary, or for overcharging or double billing Medicare beneficiaries. So the False Claims Act those violations are pursued by the Department of Justice in federal court, but CMP are administered and pursued by the OIG before an HHS administrative law judge. So depending on the offenses, the penalties can vary from 10,000 to $100,000.

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The following are some circumstances that might lead to a CMP liability. Making a false record that helps secure payment for a false claim for an item or service furnished under a federal health care program. Failing to report and return a known overpayment. Committing acts known to be in violation of the federal anti-kickback statute. Submitting a claim for an item or service that is known to not be medically necessary. Arranging for services to be delivered by an individual who is excluded from participation in a federal health care program, and just presenting a claim that’s known to be fraudulent. As an example, in 2016 a chiropractor in Kansas had to pay a civil monetary penalty of $12,494 because he failed to renew his license, and he was providing care without an active license, and so he was fined with a civil monetary penalty.

CMPs can also be placed against someone who offers remuneration to Medicare or state health care programs that the person knows can influence beneficiary selection of a provider or supplier when the payment is made. Exceptions to the beneficiary inducement CMP is when there’s a non-routine waiver of co-pays or deductible based on financial need or preventive care incentives or items or services that promote access to care but pose a low risk of harm, and items and services that are tied to financially needy beneficiaries. In addition, the 21st Century Cures Act gave the OIG the authority to penalize health IT vendors and providers for what’s called information blocking, and this is when an individual entity interferes with or discourages access to electronic health information. These penalties can incur CMP fines of up to a million dollars. So that may not apply to you as a clinician, but certainly something to be aware of, and it may apply if you actively try to block patients from their information. So those are those five big federal laws that you should be aware of as you, as you work on your compliance plan for OIG.