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Self-disclosure protocol clarified

Radiology Administrator's Compliance and Reimbursement Insider, September 1, 2008

If you suspect billing mistakes in your radiology department, contact your facility’s compliance officer. The nuanced logistics of reporting such mistakes require a coordinated response despite guidelines released in April by U.S. Department of Health and Human Services Inspector General Daniel R. Levinson. In the April 15 “Open Letter to Health Care Providers,” Levinson instituted changes and clarifications to the provider self-disclosure protocol (SDP). The clarifications are intended to increase efficiency and to benefit providers who self-disclose.

The Office of Inspector General (OIG) released the first SDP in 1998. Since then, it has encouraged the healthcare provider community to voluntarily disclose self-discovered evidence of potential fraud. The clarifications represent great news for radiology practices, says Michael F. Schaff, Esq., a healthcare attorney at Wilentz, Goldman & Spitzer, PA, in Woodbridge, NJ. “But we’ll have to keep a careful eye on things,” Schaff adds.

Among other changes, many radiology providers who self-disclose may no longer be required to enter into corporate integrity agreements. The following is a look at the highlights.

SDP requests must contain four elements

To improve the disclosure process, the open letter states that the initial submission must contain the following information:

A complete description of the conduct being disclosed

A description of the provider’s internal investigation or a commitment regarding when it will be completed

An estimate of the damages to the federal healthcare programs and the method used to calculate that figure or a commitment regarding when the provider will complete such estimate

A statement of the laws potentially violated by the conduct

This information must be included in addition to the basic information described in the SDP. The provider must be in a position to complete the investigation and damages assessment within three months after acceptance into the SDP. Remember, it’s a good idea to talk to your attorney before beginning the SDP process, Schaff says.

OIG promises quicker resolution

In addition, the open letter states that the OIG streamlined its internal process for resolving these cases. In turn, the OIG expects full cooperation from disclosing providers during the verification of the disclosed matter. The OIG will remove providers from participation in the SDP unless they disclose in good faith and respond to the OIG’s requests for additional information in a timely manner.

Providers’ good faith is essential

The open letter notes that the efficiency of the SDP also depends on providers’ good faith determination that the matter implicates potential fraud, rather than a mere billing mistake.

The SDP intends to facilitate resolution of matters that potentially violate federal criminal law, civil law, or administrative laws for which exclusion or civil monetary penalties are authorized. Thus, you should submit billing errors or overpayments directly to the appropriate claims-processing entity, such as the Medicare contractor, not through the SDP process.

Effective compliance program measured

To determine that a provider adopted effective compliance measures, the OIG checks to see that providers:

Offer a complete and informative disclosure

Respond quickly to the OIG’s requests for further information

Perform an accurate audit

When it negotiates the resolution of the OIG’s applicable administrative monetary and permissive exclusion authorities in exchange for an appropriate monetary payment, the OIG generally will not require the provider to enter into a corporate integrity agreement or certification of compliance agreement.

The OIG believes not requiring a compliance agreement can recognize the provider’s attempt to renew its commitment to integrity. The new SDP, the OIG says, also advances its goal of expediting the resolution of self-disclosures.

Insider source

Michael F. Schaff, Esq., Wilentz, Goldman & Spitzer, PA, 90 Woodbridge Center Drive, Suite 900, Box 10, Woodbridge, NJ 07095-0958, 732/855-6047; mschaff@wilentz.com.

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