Successful negotiation may ease CIA complexity
Successful negotiation may ease CIA complexity
Despite publicized attempts by the Department of Health and Human Services Office of Inspector General (OIG) to reign in the complexity of corporate integrity agreements (CIAs), the size and scope of these OIG-mandated agreements continue to grow. (See related story, page 3.) "The evolution of the technical portion of CIAs over the last several years is astronomical and something we need to play close attention to," asserts Robert Bacon, director of compliance for the University of Pennsylvania Health System. "No two are the same; they are all different."
According to Bacon, there is tremendous variation in the specific criteria in the CIAs that are signed today compared to the settlement that his health system agreed to in 1995. For example, specific hours and training by full-time equivalent type are now frequently specified, whereas earlier agreements merely included a requirement to conduct education.
More recent CIAs also include expanded requirements for filing reports, notes Bacon. "That is another example of where I have seen astronomical changes in the last five years," he asserts.
Bacon says he is also concerned that providers will have to file an audit report along with the management report. That puts the onus on organizations to report additional information that the CIA did not require, but that now potentially becomes part of public records under the Freedom of Information Act. "I am very concerned in this area," he says.
Bacon also cautions that all entities under CIAs should be familiar with SOP 99-1, which is the American Institute of Certified Public Accountants’ guidance to practitioners in conducting and reporting on CIAs, introduced last year. "This is a document that certainly concerns me," says Bacon. He says that is because the testing procedures go above and beyond anything that was required in many of the earlier CIAs.
For example, SOP 99-1 includes requirements for testing audit records against payroll records. "None of this is required in many existing CIAs, but it is clearly mentioned in the agreed-upon procedures," he reports.
Bacon also predicts that specific references to SOP 99-1 will be included in future settlements. "However, if you are not required to do that level of testing on your current agreement, the cost of bringing in that external auditor to follow those procedures is significant," he asserts.
Patrick Marion, president of Compliance Concepts in Philadelphia, reports that for most of the CIAs that have come out over the last year, the independent review organization (IRO) is instructed to review the implementation of the CIA as well as the detailed claim review.
Marion, formerly a member of the OIG, says that gets back to the negotiation of the CIA. He points to one institution where the CIA audit requirement was not to audit the claims submission but rather the internal audits that it had conducted.
"That is much different than having an independent firm take a sample of claims, replicate an audit, and come up with an overpayment as opposed to evaluating whether the audits were timely and thorough." That change probably saved the organization $100,000, he adds.
Marion says one important area to examine with an external review organization is its track record and experience in dealing with the federal government in areas such as auditing procedures.
"If you are going to bring somebody in to look at physician claims, you don't want somebody who has worked on 25 lab settlements," he warns. "You need that specific level of expertise on the issues they are dealing with."
Marion says one of the specific issues an IRO must be familiar with is the OIG's statistical program. He notes that the OIG's audit division has very specific rules on how it performs statistical sampling and what it must report. However, the investigative arm of the OIG is not obligated to follow those rules. "If you can bring to the table your knowledge of those rules, the difference on the same errors can be literally millions of dollars," he says.
According to Bacon, deciding whether to involve a specialist requires looking at the subject matter. That might mean attorneys for interpretation of specific regulations, medical specialists, or board certified physicians.
Bacon cites one audit dealing with urological procedures that used both internal- and external-board certified urologists to help overturn the audit. Likewise, he says cost-reporting issues may require accountants with specific expertise in those issues.
Marion adds that while organizations may engage clinical experts, somebody must be responsible for managing the entire process. "You may have multiple clinical specialties involved, and you need a person who is going to be able pull all of those independent pieces together and put them in a package to present to the government," he explains.
According to Bacon, once the shadow audit is completed and a CIA has been reached, the need to perform continued shadow audits is often redundant.
But he says there needs to be an assembled team that will investigate any unfavorable variances. IRO findings can be wrong, he warns. For example, records may have been overlooked or the interpretation of a physician's shorthand may be subject to interpretation. "If you go through those unfavorable findings, you should be able to reduce any liability attributable to the error rates," he says.
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