OIG guidelines useful for private duty

The Department of Health and Human Service’s Office of Inspector General (OIG) issued compliance guidelines for federal laws in August 1998. The guidelines apply specifically to providers operating under the Medicare program, but may serve as a useful template for private duty providers developing a corporate compliance program. Intended only as a reference, and not an antidote to prosecution, the guidelines cover the following areas:

    • fictitious care plans, certifications and beneficiary signatures;

    • billing for services that are either substandard or not performed;

    • billing for services that are medically unnecessary based on a patient’s documented medical condition;

    • duplicate billing and failure to refund credit balances or overpayments promptly;

    • providing incentives to potential referral sources that may violate anti-kickback laws;

    • billing for services provided to patients who are not homebound;

    • over- and underutilization of services, including financial incentives based on the number of visits and/or revenue generated;

    • billing for non-reimbursable services such as coordination of care;

    • arrangements with physicians who violate the Stark anti-referral law;

    • financial incentives that reward practitioners for referrals to the home health agency or otherwise violate the anti-kickback statute;

    • patient abandonment or termination of services.1

Don’t forget proscriptions of activities that involve conflict of interest, antitrust and political activism, says Randy Boston, RN, MA, president and chief executive officer of Austin, TX-based Healthcare Executive Resources, a health care consulting firm.

Keep in mind that "it’s not just what’s happening in your agency, it’s what people think is going on that is important," he says. For example, if you invite your top referral sources to a company Christmas party, your only intention may be acknowledging those with whom you have a good relationship and who value your services. Others may interpret the action as an inducement for more business.

Copies of the OIG guidelines are available on the Department of Health and Human Services. Web site: www.dhhs.gov/progorg/oig.


1. Adapted from presentation given by Arent, Fox, Kintner, Plotkin & Kahn, Washington, DC.