OIG model helps hospitals avoid ‘Labscam’ fines

The Office of the Inspector General (OIG) in Washington, DC, has unveiled a "Model Compliance Plan for Clinical Laboratories" that provides some specific guidelines hospitals can follow to minimize the risk of federal prosecution for claims and billing misdeeds.

The 12-page plan, prepared by the OIG in concert with other federal agencies and the private sector, is directed at laboratories but offers insights into features the agency expects in all compliance plans.

The model was developed as part of the government’s Lab Unbundling Project, also called "Labscam." More than 2,000 hospitals have been targeted by the OIG for illegally unbundling Medicare and Medicaid outpatient lab charges. The guidelines are the government’s suggestions on how to correct and prevent fraudulent practices, and they can be tailored to fit individual situations, the agency says. Key features include:

1. Adopt written procedures and policies.

Give them to all affected employees. The OIG suggests they be put in a three-ring binder so amendments can be made. The policies should include the following:

Standards of conduct. These should help employees determine policies regarding fraud, waste, abuse, and adherence to all federal guidelines. They also should be prepared in as many different languages as necessary.

Medical necessity. Be prepared to show that any claims are backed up by proof of medical necessity. Proper documentation can include requisition forms containing diagnosis codes. Also be prepared to educate physicians about their need to document medical necessity. The guidelines state that all laboratories should provide annual written notices to physicians delineating the lab’s policies on medical necessity and details about its billing policies. Each physician also should sign an acknowledgement that he or she is familiar with the policies.

2. Comply with OIG alerts.

Include these in the policy manuals and immediately correct any deficiencies.

3. Retain your records.

"One of the best ways to confirm that a compliance plan is effective is through reports that reflect results," the OIG plan states. But make sure you address patient confidentiality issues, it warns.

4. Tie compliance with performance. When managers and supervisors are given their performance evaluations, the degree to which they acted on and promoted the compliance plan should be considered.

5. Educate and train.

Employees should be given compliance and ethics training annually. Workers should be educated about what’s in the plan and told that their continued employment depends on following the guidelines.

6. Create a hotline.

This could be a telephone hotline, e-mail, or written communication, but the telephone might be best, the model plan states. Notices should be posted informing workers of the hotline number.

7. Audit and monitor.

Conduct regular systematic audits of operations. This should include visits to all pertinent sites, interviews with the people doing the work, a review of written materials and documentation, and a trend analysis.