Corporate Compliance

Tip: Avoid Medicare exclusion

Compliance Monitor, November 17, 2010

The Supplemental Compliance Program Guidance for Hospitals states that the OIG will exclude from Medicare those individuals and entities that provide substandard or unnecessary items or services, regardless of the party’s knowledge or intent. The OIG’s exclusion authority covers unnecessary or substandard items or services provided to all patients, including non-Medicare and non-Medicaid beneficiaries

The OIG says hospitals should:

  • Continually measure their performance against comprehensive standards, such as the Medicare Conditions of Participation
  • Develop their own quality-of-care protocols and adopt mechanisms for evaluating protocol compliance
  • Expand reviews of nursing and other ancillary services to include the credentialing and peer review of medical staff

Furthermore, the guidance warns that hospitals run a risk if they knowingly fail to provide covered services or necessary care members of a health maintenance organization.

This week’s tip was adapted from The Compliance Program Effectiveness Handbook. For more information about the book or to order your copy, visit the HCMarketplace.

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