OIG targets maximizers: How to stay off the hit list
When the federal Office of the Inspector General (OIG) announced the release of its compliance program guidance for hospitals, they also dropped a bombshell on all organizations that have ever employed a consultant to maximize Medicare reimbursement.
Basically, if during the course of an audit, OIG investigators find evidence of billing fraud in a hospital that used a particular coding consultant, they may subpoena that consultant's client list and go after every other facility on it, says Larry Goldberg, JD, chief of the civil recoveries branch of the OIG's office of counsel.
"Should we ever find out information that it was the practice of a particular company to maximize inappropriately and might establish an independent basis for an investigation of other accounts that that company had, then that would be in the realm of OIG's investigative authority and responsibility," Goldberg says.
"That's really scary," says F. Lisa Murtha, JD, senior manager and director of control and compliance practice at Deloitte & Touche LLP in Philadelphia and consulting editor of Compliance Hotline. "It doesn't surprise me, but it's unfortunate, because a lot of what consultants do in a given case is specifically at the request of a particular client."
A precedent for such action on the part of OIG was set when Metzinger and Associates, a consulting firm that assisted clients with maximizing reimbursement, was investigated by federal authorities a couple of years ago.
Investigators asked the firm to divulge confidential results of its reviews and went after it for the advice it had given its clients, Murtha says.
"That case really made all consultants very wary of getting involved in any practices that were even remotely risky," Murtha adds. "In today's environment, people won't push the envelope anymore, and if they do, they're making a mistake."
If you've used a maximizing consultant in the past, there still are ways to reduce your liability. The first of these, of course, is to have a corporate compliance plan in place that's designed to prevent and detect any sort of billing irregularities that might encourage investigative attention. "Even if other things had happened in the past, having a mechanism in place now would be critical to your defense," Murtha says.
Your organization could also elect to perform an extensive billing and coding review and voluntarily reimburse the government for any overpayments you find. "It's a risk, no doubt about it," Murtha says. "But those organizations that really think they may have some trouble will know who they are. And if it were me, I would rather be the one going to the government than to have the government come to me first."
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