In its recent Open Letter to Providers (“Letter”), the Department of Health and Human Services Office of the Inspector General (“OIG”) further refined and streamlined its Provider Self-Disclosure Protocol (“SDP”).
OIG created SDP in 1998 to encourage providers to voluntarily disclose Medicare billing fraud and abuse. It provides such encouragement by creating a framework for reporting fraud and abuse, coupled with reduced penalties for reporting providers, i.e., typically resolving self-disclosures at a multiple of the amount of the benefit conferred, as opposed to a multiple of per-claim statutory amounts. OIG considers SDP a great success and credits it with returning more than $120 Million to the Medicare Trust Fund. SDP is not an appropriate vehicle for resolving routine billing mistakes or overpayments. These sorts of issues should be addressed to the appropriate Medicare contractor. However, SDP is appropriate for disclosing unlawful billing practices (e.g., Stark violations) that are so significant that the provider credibly risks exclusion from Medicare/Medicaid or monetary penalties under controlling law. Providers who voluntarily disclose billing practices through OIG’s SDP have the ability to avoid certain penalties so long as they fully disclose all details, provide appropriate reimbursement to the respective Federal program and cooperate with OIG in ensuring that any necessary remedial steps are taken to avoid future errors.
A provider’s initial submission must contain the following:
- Complete description of the conduct being disclosed;
- Description of the provider’s internal investigation (or commitment as to when the same will be completed);
- An estimate of the damages to the respective Federal healthcare program, together with a description of how the amount was calculated (or commitment as to when the same will be provided); and
- Identification of the law(s) potentially violated by the conduct.
- In addition to these changes regarding initial submissions, OIG has modified its default position regarding the requirement of a Corporate Integrity Agreement (“CIA”) or Certification of Compliance Agreement (“CCA”) in the event of a disclosure. In the past, it was commonplace for OIG to require a CIA or CCA with providers who participated in SDP; however, OIG has now indicated that it will be predisposed not to require a CIA or CCA.
Finally, OIG indicates that it has streamlined its internal processes so as to expedite SDP resolution. Likewise, it has expressed its intention to require providers to reciprocate by responding in an expeditious manner.
Disclaimer: The information contained within the MTBC® Learning Center is provided for general educational and informational purposes only and should not be construed as legal advice. The author of the Learning Center does not represent the Web site user or the individual submitting a particular question. Please seek the advice of legal counsel to address any specific questions you may have regarding your particular facts or circumstances