In what can be viewed as a roadmap of likely future enforcement initiatives, the Office of Inspector General ("OIG") issued supplemental compliance guidance in the June 8, 2004 Federal Register. This new guidance supplements the OIG's previous recommendations regarding the structure and content of hospital compliance programs. The OIG's guidance is particularly helpful in that it provides insight regarding a number of risk areas that the OIG deems to be particularly important. Hospitals will do well to pay attention to issues identified in the guidance since future enforcement activities will likely be focused on these areas.
The supplemental guidance lists eight general areas of potential risk:
- claims submissions especially in regard to Medicare's outpatient prospective payment system ("OPPS");
- patient referrals;
- payments to reduce or limit services (e.g., gainsharing arrangements);
- substandard care;
- relationships with beneficiaries;
- HIPAA privacy and security rules; and
- billing in excess of usual charges.
The guidance also addresses areas of "general interest" to the hospital community, including discounts to uninsured patients, preventive care services, and professional courtesies. The OIG's guidance also discusses the importance of hospital leadership taking an active role in the organization's compliance activities and the need for on-going self assessment of existing compliance programs.