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Common elements found in CIAs

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

The OIG offers providers the option of settling civil healthcare fraud and abuses cases through a corporate integrity agreement (CIA). The agreement, arranged between the government and the provider, allows the provider to avoid exclusion from federally funded healthcare programs.

Such exclusion is typically dubbed the proverbial death sentence for healthcare providers.

Instead, the provider has the opportunity to continue to treat Medicare patients, as long as it complies with a contract with the OIG requiring it to conduct its business according to certain principle. That contract is the CIA. CIAs are like compliance programs with a few important differences. The most important difference is that a compliance program is voluntary and you develop it yourself, considering the needs and resources of your practice.

Mandatory program pieces

A CIA is anything but voluntary, and the government’s attorneys, with input from you, will decide how it should be structured and how much of your resources you should devote to it. Although there’s room for limited negotiation on a case-by-case basis, all CIAs require the following common elements:

Training. CIAs are specific about the type and amount of training your employees must have. Recognize that the amount of training the OIG thinks your employees need might be more than you think they need or want to pay for.

Auditing. CIAs always provide for stringent audit-ing, usually conducted periodically by an indepen-dent review organization, such as an accounting firm that you must pay for. But if your practice already has good in-house auditing capabilities, it doesn’t hurt to ask whether you may conduct the audits yourself, rather than use an independent review organization.

Monitoring. The OIG might also require that an independent review organization monitor your practice to ensure that you have systems operating properly to prevent a recurrence of a compliance violation. (It might be the same company that’s providing the auditing services, or it might be another one—it depends on what the OIG thinks the problem areas are.) Just like the auditors, these monitors will be a frequent presence. And they’re required to report to the OIG if they notice any problems in your practice. Additionally, the OIG can penalize you if it decides that the independent review organization isn’t doing its job properly.

Reporting. CIAs always include strict reporting requirements. Not only will your independent review organization have to report your activities, but you’ll have to prepare reports as well, including:

Identifying your compliance officer and establishing that he or she is a high-level employee

Certifying that all required employee training has been completed

Certifying that you’re complying with applicable laws, rules, and regulations

Depending on how you received your violation, your CIA may include other, sometimes substantial, reporting requirements, such as penalty fines ranging from $1,500 to $2,500 per day for a violation of the agreement and exclusion from Medicare.

CIA draft advice

Ideally, you’ll never have to negotiate a CIA. Practicing under one is a burden, and things will never be the same.

However, if you’re in trouble with the government, a CIA might be better than exclusion—at least you’ll stay in business and continue to treat your Medicare patients.

Keep the following in mind if you’re ever in that unfortunate situation:

Get good advice. You can’t do it alone. Hire the best healthcare attorney to advise you on the financial and practical implications of this agreement, and ask him or her to hire an auditor to negotiate the auditing provisions of the agreement.

Take a cooperative attitude. The OIG views its CIAs as educational tools, not punishment. If the OIG believes you want to improve your operations and are willing to learn from the process, it is more likely to listen to your concerns. That means you might be in a better position to protest if the OIG wants to impose requirements that won’t work for you on an operational level or don’t address the previous issues.

Keep expectations reasonable. Accept that operating under a CIA is going to cramp your style in some ways. Rather than protesting everything in the agreement, think about where the heaviest administrative burdens are likely to fall and try to negotiate for less onerous conditions in those areas. Also, keep in mind that the CIA teaches you how to conduct your business in a compliant manner. The OIG is more likely to listen to suggestions that foster practical knowledge and compliance after the agreement ends.

Editor’s note: Content is adapted from the Radiology Manager’s Handbook: Tools and Best Practices for Business Success, published by HCPro, Inc.

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