• The Gist: The Deficit Reduction Act now shifts federal enforcement focus to Medicaid.
By Angela L. Tobias, RN, BSN, MSHSA, LNCC
As of Jan. 1, 2007, healthcare organizations receiving $5 million or more in Medicaid payments per year must take steps to show compliance with the Deficit Reduction Act.
The Deficit Reduction Act demands certain steps of healthcare providers:
• Have a written policy and procedures in place that give to all employees, including management and any contractor or agent, detailed information concerning the False Claims Act, whistleblower protections, and provisions about the facilities’ policies and procedures for detecting and preventing fraud, waste and abuse.
• Have specific discussions in the employee handbook of the policies and procedures and each employee’s right to be protected as a whistleblower. The Homepage of this website has information regarding the same and it might do you well to look it up.
Whistleblowers are individuals employed within healthcare institutions who detect and report organizational fraud and abuse.
Whistleblowers may not be retaliated against for reporting, and are entitled to a percentage of the federal government’s recovery should the federal government decide to pursue the reported claim and obtain monetary recovery. These claims are usually registered when the employee whistleblower has exhausted all efforts to inform the organization of the discovered abuse, yet the abuse is continued.
Written policies for detecting and preventing fraud, waste and abuse are now a mandatory part of compliance programs. All compliance programs must step up to the plate and establish policies and procedures explaining their organization’s plan for the prevention and detection of fraud and abuse.
Education is crucial to keep everyone informed about key components of an organization’s compliance program and its efforts to detect waste, fraud and abuse.
Compliance programs are effective when they include provisions for the identification of compliance risk within the organization, and provide for steps to address those risks. The goal is to produce insurance, private payer, Medicare and Medicaid claims that are clean (reflect accurate charges for services provided) before the patient/client bill is ever sent out.
A new Medicaid Integrity Program has been staffed with federal agents to lead national Medicaid enforcement activities.
Several programs have also been formed to track best practices and benchmark data. Medicaid claims error rates, as well as the comparison of Medicare to Medicaid claims data to find patterns of fraud, will be conducted under this act.
Organizations that have effective compliance programs will seek ways to encourage reporting of incidences of inappropriate conduct or illegal practices. The goal is to create a “culture” within the organization that encourages compliance to all healthcare rules and regulations, and federal and state laws. •
Angela L. Tobias, RN, BSN, MSHSA, LNCC is co-owner of Nightingale Consulting, LLC a legal nurse consulting firm located in Dalton, Ga. She has served as a hospital CEO and corporate compliance officer;firstname.lastname@example.org.