CEOs Get a Medicare Compliance Checklist

Since its inception in March 2007, the Medicare Fraud Strike Force has charged more than 1,480 defendants who collectively have falsely billed the Medicare program for more than $4.8 billion.

The fraud agents are not done, however, one healthcare leader warns.

"The government Medicare enforcement agents are under added pressure to increase their fraud recoveries," says Roy Snell, CEO of the Health Care Compliance Association in Minneapolis.

"The pressure has increased due to the cost of healthcare reform and concerns about addressing the deficit. The list of Medicare compliance issues you should be concerned about are too long to list, but they are outlined in detail in the Office of Inspector General’s annual Work Plan."

The Medicare Fraud Strike Force was in full force just a short three months ago. A seven-city operation, part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), led to charges against 91 individuals including doctors, nurses and other licensed medical professionals for participating in Medicare fraud schemes involving approximately $429.2 million in false billing.

CEOs can ensure their organizations' compliance programs are functioning as intended by following these guidelines:

1.Hire experienced compliance professionals. "It’s very simple," Snell says of a healthcare CEO’s role in compliance. "Hire an experienced compliance professional to manage a comprehensive compliance program and give him/her the independence and authority to fix the problems he/she finds. Increasing the compliance resources is helpful, but without the freedom to prevent, find and fix fraud, the CEO will always be facing an uphill battle."

2.Ensure no one gets in the way. Healthcare CEOs should ensure that compliance officers  are free of interference and able to do his/her job, Snell adds. "In my opinion, it is the single biggest impediment to the CEO’s success with a compliance program," the HCCA chief says.

3.Make time for your chief compliance officer. Your compliance officer should meet with you on a regular basis. During these meetings, the compliance officer should share reports showing all the functioning elements of the compliance program and provide a list of the issues that have been discovered by or reported to the compliance program, Snell adds.

4. Request audit reports. "An audit report listing the work being done to ensure you have addressed the issues identified on the OIG Work Plan would be helpful," Snell says. "The CEO should be informed of anyone interfering with the implementation of the compliance program or interfering with the resolution of issues."

5. Encourage balance between OIG and peers. Ensure that compliance officers focus on the issues the OIG intends to investigate, but also on issues that the compliance officer identifies from conversation with his/her peers in the field. "There should be a balanced effort on all the elements of a compliance program," Snell says, "but I would focus more on auditing and resolving problems."

6.Keep the board informed. The CEO should not deliver the compliance reports to the board.  Rather, the compliance officer should meet with the CEO prior to the board meeting, and together they should report to the board. "The reports should be essentially an executive summary of the reports mentioned previously," Snell says.