Corporate Compliance

Tip: Determine if benefits outweigh risks when it comes to voluntary disclosure

Healthcare Auditing Weekly, November 11, 2008

The balancing of benefits and risks of voluntary disclosure is complex and should be undertaken only with advice of counsel. If the best direction is not clear, answer the following questions to help inform the decision-making process:
  1. Can you handle the situation as an ordinary matter? If providers can withdraw or amend erroneous claims before adjudication by the fiscal intermediary, they can “disclose” in that way, thereby potentially avoiding the additional expense and aggravation of having the claims considered to be disclosures. Usually, this option is limited to claims pending in the intermediary system.
  2. Are the circumstances and seriousness of the underlying misconduct such that a self-disclosure is likely to reduce the burden of an investigation and thereby mitigate any penalties?
  3. What is at stake? Is someone’s personal freedom at risk because of a potential jail sentence? If a federal healthcare program financial loss has occurred, what was the extent of such loss? Is the provider willing to repay the overpayment? If not, can the provider seek to reduce the penalties based on its ability to pay?
  4. Has the provider had the same or similar problems with the OIG, CMS, the carrier, the intermediary, or the state? Is there evidence that the provider knew, or should have known, that his or her conduct was prohibited?
  5. Is the provider willing to make necessary changes in billing practices, standards of conduct, and internal control systems to ensure compliance with the law going forward?
This tip is adapted from The Compliance Officer’s Handbook. For more information about the book or to order your copy, visit HCMarketplace.

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