OIG won’t seek penalties for outpatient PPS errors
HCFA offers resources to aid implementation
The Office of Inspector General (OIG) has announced that it will not seek civil or criminal penalties for innocent errors, mistakes, or even negligence committed by outpatient providers during the implementation of the outpatient prospective payment system (PPS).
"The government’s primary enforcement tool, the civil False Claims Act (FCA), 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," said June Gibbs Brown, inspector general, in a June 23 letter addressed to the American Hospital Association.
The OIG listed some examples of mitigating factors that the agency will consider when deciding whether the impose civil or criminal penalties. Those factors include:
• the clarity of the regulation;
• the complexity and novelty of the billing system;
• guidance from the Health Care Financing Administration (HCFA) and fiscal intermediaries;
• the extent to which the provider has attempted to understand the regulation;
• the quality of training provided for billing personnel;
• whether the provider has an effective compliance program.
The outpatient PPS is scheduled to be implemented for hospital outpatient departments on Aug. 1. The ambulatory surgery center PPS is scheduled to be published in November 2000 and implemented in April 2001.
Other news
If a hospital hasn’t had an off-campus same-day surgery program designated as provider-based, but the hospital treats it as provider-based, the hospital might not be required to apply for provider-based status in order to submit claims after Oct. 10, 2000, according to the McDermott, Will, and Emery law firm.
However, if HCFA challenges the provider-based status of the same-day surgery program, the hospital must demonstrate that the program meets the criteria to be designated as provider-based. Otherwise, HCFA can recoup past payments, according to the firm.
HCFA has set up a reference guide for the outpatient PPS on its Web site (www.hcfa.gov/ medlearn/refguide.htm). The reference guide includes a booklet of "Frequently Asked Questions and Answers," which also are available in printed form.
(For an excerpt of those questions and answers, see the Medicare Learning Network insert, enclosed in this issue.)
At press time, HCFA was setting up an outpatient PPS listserve and links to local fiscal intermediaries on its Web site.
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