Burr & Forman

11.12.2018   |   Articles / Publications

The OIG Reminds Healthcare Providers of Fraud Risk Factors When Deciding Whether to Exclude a Healthcare Provider or Require a CIA

Reprinted with Permission from the Birmingham Medical News

With the continued proliferation of qui tam False Claims cases showing no signs of slowing down, not only must providers consider the amount of any monetary settlements, they must also consider whether the Office of Inspector General for the Department of Health & Human Services (“OIG”) will require a corporate integrity agreement (“CIA”). The OIG recently published a reminder to all providers of the risk factors it uses when determining whether or not to exclude a provider and/or require a CIA.

As most providers are aware, the False Claims Act (“FCA”) is the government’s primary civil tool for addressing healthcare fraud. While most FCA cases are resolved through settlements involving monetary payments, the OIG retains the right to determine whether or not to exclude a party and/or require a CIA. Based on the information it gathers in an FCA case, the OIG assesses the future trustworthiness of the settling parties for the purpose of deciding whether to exclude them from the Federal healthcare programs. The OIG applies published criteria to assess future risk and places each party to a FCA settlement into one of five categories on a risk spectrum. OIG uses its exclusion authority differently for parties in each category. OIG bases its assessment on the information OIG has reviewed in the context of the resolved FCA case and does not reflect a comprehensive review of the party.

The OIG has a range of administrative options it can exercise. Depending on the facts and circumstances of the particular case, the OIG will usually pursue one of the following approaches when settling a civil or administrative health care fraud case: (1) exclusion; (2) heightened scrutiny (e.g., implement unilateral monitoring); (3) impose a CIA; (4) take no further action; or (5) in the case of a good faith and cooperative self-disclosure, release 1128(b)(7) exclusion with no integrity obligations.

Download the full article “The OIG Reminds Healthcare Providers of Fraud Risk Factors When Deciding Whether to Exclude a Healthcare Provider or Require a CIA” written by James A. hoover.

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