OIG on PPS: Hospitals should not fear mistakes
AHA waits for more details
Are you concerned about how the Office of the Inspector General (OIG) in Washington, DC, will handle billing errors after the implementation of the outpatient prospective payment system (PPS)? The OIG has given you guidelines — sort of.
In a June 23 letter to Dick Davidson, president of the American Hospital Association (AHA) in Chicago, Inspector General June Gibbs Brown admitted that errors may occur from implementation of the "new and complex" system.
Hospitals, however, should not fear innocent errors, mistakes, or even negligence, she wrote. "The government’s primary enforcement tool, the civil False Claims Act, covers only offenses that are committed with actual knowledge of the falsity of the claim, reckless disregard of the truth or falsity of the claim, or deliberate ignorance of the truth or falsity of the claim," she stated. "The other major civil remedy available to the federal government, the Civil Monetary Penalties Law, has exactly the same standard of proof."
When billing errors, honest mistakes, or negligence result in erroneous claims, the hospital will be asked to return the funds erroneously claimed, but without penalties, she added. Brown advised hospitals to begin a voluntary compliance program to help identify erroneous claims, correct the underlying problems causing the erroneous claims, and ensure that any overpayments caused by such erroneous claims are promptly returned to the government.
If hospitals are questioned regarding improper billing under the outpatient PPS, the OIG will look at a variety of factors, she says, such as:
• the clarity of the relevant rule;
• the complexity and novelty of the billing system at issue;
• the guidance issued by the Health Care Financing Administration and/or its agents (such as fiscal intermediaries);
• the extent to which the provider has attempted to ascertain an understanding of the relevant rule;
• the quality of the efforts of the provider to train personnel on the billing system;
• whether the provider has an effective compliance program in place.
The AHA is pleased that the OIG has recognized the complexity associated with the PPS transition, says Rick Pollack, AHA executive vice president.
However, the letter leaves several questions unanswered, says Dionne Dougall, AHA’s assistant director of media relations. "Specifically, how is the OIG going to deal with the billing errors that are likely to occur if the [PPS] implementation isn’t done smoothly and accurately?" Dougall says the AHA is waiting for further clarification from the OIG.
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