Limit scope of corporate integrity agreements
Many health care providers have barely had time to implement their corporate compliance plan, and nearly 400 of them are being forced to cope with another major challenge — corporate integrity agreements (CIAs). Now, besides growing in number, CIAs are increasing in size and scope.
In expectation of an increasing number of agreements, the Department of Health and Human Services’ Office of Inspector General (OIG) is now beefing up its CIA oversight staff. Many existing CIAs derived from the OIG’s 72-hour window project and other focused investigations and are limited in scope. But the new generation of CIAs tend to be more expansive.
According to Mac Henderson, a partner with PriceWaterhouseCoopers in Washington, DC, the No. 1 one pitfall for CIAs is lack of planning. "When that happens," he told a panel at the Health Care Compliance Association’s (HCCA) Annual Conference in Chicago on Oct. 25, "what you see is a migration in the CIA to cover a lot of areas that never had a billing problem."
Providers should resist that tendency, says Henderson. "You are going to get killed if you just accept the boilerplate, which is what you will get the first time around." Instead, he says, providers should take their existing plan and try to sell it to the OIG. "Go in there and say to the OIG, I would like to make a presentation on what we are currently doing, and let’s see where the CIA fits in.’"
Henderson advises providers to take a proactive role in negotiating CIAs. "We do want to negotiate these agreements very vigorously and come back and challenge them."
According to Henderson, there are two components to negotiating a successful CIA. First, providers should make sure the OIG understands what existing compliance programs are already in place and have those programs acknowledged. "The second issue is that everyone wants to ensure compliant billing," says Henderson, "so you want to imbed the CIA in some of those existing processes."
Here is a rundown of several other specific areas that Henderson suggests hospitals and other providers pay close attention to when negotiating a CIA.
- Examine existing CIAs. "There are some very good agreements out there," he says. "Some providers have done an excellent job of planning ahead." But he adds that the OIG is now pushing back and becoming very specific. That often includes requiring detailed, specific procedures.
Henderson points to the Georgetown University Medical Center CIA, which came about in the wake of a Physicians at Teaching Hospitals investigation as an example of "an excellent CIA." He says successful negotiation managed to limit the scope of the agreement itself, as well as the scope of the Independent Review Board (IRO).
- Establish effective communication. "My recommendation is that you talk to the OIG a lot," says Henderson. "That is where you are going to get your ability to modify your procedures."
He says the latest development at the OIG is the use of a team approach. "They seem to be matching different skill sets for different types of CIAs," he says.
Another reason for consistent communication is turnover at the OIG, says Andrea Bohannon, associate compliance officer at Laidlaw in Dallas. "You have a lot of turnover at the OIG, and you might have someone brand new that does not know your business and does not really know what the negotiator intended you to do because it is so broad," she says. "They are ramping up their staff; so I think you are going to see more communication back and forth."
- Limit the scope of the IRO. Henderson also emphasizes the importance of defining the role of the Independent Review Organization (IRO). "The IRO is not there to be your end-all or be-all consultant," he says. He also warns hospitals against letting the IRO conduct a broad-based risk assessment.
In fact, letting to IRO wander too far may even carry legal risk, according to Henderson. "If the IRO is actually giving compliance consulting services, you may have violated the independence definition," he explains. "The OIG does not want an IRO reviewing policies and procedures that the IRO itself implemented."
According to Lew Morris, HHS Office of Inspector General (OIG) associate inspector for legal affairs, while CIAs always include several core features, many areas of a CIA are negotiable. "Some of the most successful negotiations we have had with providers have been without outside counsel present," Morris told a panel at the HCCA conference. "Those providers who have the courage to come in the lion’s den and sit down with us, I think, have been refreshingly surprised at how we deal with them."
"Outside counsel does not have to live under the CIA," he adds. "If the CIA is negotiated in an acrimonious atmosphere with a win-lose mechanism, the people that are going to lose are providers that have to live under it."
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content