OIG signals increased flexibility on integrity agreements

American Hospital Association continues to take a hard line on the proliferation of CIAs

Amid growing concerns about the costs imposed by corporate integrity agreements (CIAs) on hospitals and other health care providers, the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) got high marks for its July 30 roundtable aimed at coming up with solutions for the most onerous aspects of these agreements.

"It was a very positive interaction with a lot of dialogue and open discussion on a range of relevant issues," says Bret Bissey, chief compliance officer at Deborah Heart and Lung in Browns Mill, NJ, who attended the daylong roundtable in Washington, DC.

While the CIA process itself now is a few years old, Bissey says it still is very new to the industry. "It is such a new area that it has its own life cycle," he explains. "It is something that providers must adhere to culturally throughout their system."

According to Bissey, that includes educational and training requirements as well as coping with many expensive independent review organization (IRO) functions that often are difficult to measure. Complicating matters is the fact that reporting requirements and definitions included in CIAs are not well defined by the government.

All of those issues were on the table, says Gil Stone, chief compliance officer at The Medical Center at Princeton (NJ), who was among the roughly 80 health care professionals who met with OIG officials. He says major topics of conversation included the role of IROs, statistical sampling, adopting other acceptable sampling techniques in addition to the OIG’s software package known as RAT-STATS, and changing the sample selection size used by the OIG.

Also at issue was the cost imposed by those agreements, says Stone. One idea that was floated would allow some of the cost of a compliance program for a provider who is under a CIA to be included in the cost report. "Many of the costs that are not directly related to the CIA but are important to the effectiveness of a compliance program could be allowed," he explains. The hope is that the OIG will recommend that step in its final report, which OIG spokeswoman Judy Holtz expects to be completed in a matter of weeks.

Another point debated was the increasingly widespread use of CIAs, says Anthony Boswell, chief compliance officer for Laidlaw in Arlington, TX. Boswell says he warned the OIG that using CIAs for too many settlements actually undermines the process. "I would like to see CIAs implemented for companies that settle with the government for significant fraudulent issues, as opposed to mistakes or the acquisition of companies that have billing problems the parent company had little or nothing to do with," he asserts.

The Chicago-based American Hospital Association (AHA) takes a similar view. "For a provider that hasn’t violated the law itself to learn that a later violation of the CIA may be grounds for termination from Medicare is extraordinary," AHA special counsel Joseph deGenova told the Senate Special Committee on Aging late last month. He says many member hospitals believe the OIG’s increasing insistence on CIAs now is impeding voluntary disclosures as well as the resolution of billing disputes.

"We feel our CIA was unjustified," says Mary Barrowman of Montgomery General in Olney, MD, who attended the roundtable. She says the hospital mistakenly hired a physical therapist who was uncredentialed. However, when the hospital uncovered and self-reported the problem, it received the same penalties as several other home health agencies that never identified the problem on their own. The hospital was working with its fiscal intermediary to correct its cost report when the OIG moved in, reports Barrowman.

CIA training requirements are another costly issue, according to AHA. Typical agreements usually impose a mandatory minimum number of training hours per employee. "The emphasis on hours does not ensure that the training is productive or meaningful," argues deGenova. Instead, hospitals should have the discretion to conduct training in ways that they consider optimal, which might include a web-based tool as opposed to a two-hour lecture, he says.

AHA also objects to the requirement that the first wave of training must take place within 120 days after the agreement is forged, regardless of whether the actions investigated took place before the provider had a compliance plan in place.

Roundtable attendees say all these areas now are on the table. "Time will tell," says Robert Pierce, chief financial officer at Guardian Postacute Services in Corte Madera, CA.

CIAs have become a hot issue as they have proliferated over the last two years and increasingly have become an essential ingredient for providers under investigation to avoid exclusion from the Medicare program. Roughly 700 CIAs have been imposed, with about 400 of them still active. More than half of those 400 are with hospitals.

"CIAs are a day-in and day-out concern for some number of providers who are under them," says Pierce. But he says it is an area to which all providers should pay close attention. "Even if you are in the most compliant organization of all time, CIAs indicate what areas the government is concerned about and where they want focus, as well as the preferred methodologies for attacking some compliance issues," he says.