OIG may ease integrity agreement reviews

The head of the Health and Human Services Office of the Inspector General (OIG) is offering to ease up on some previously established provisions of the corporate integrity agreements (CIA) that hospitals may have abide by after being caught with their hands in the cookie jar.

Inspector General Janet Rehnquist recently issued an open letter to health care providers in which she explained that her review of previous OIG policies indicated that there had been substantial dissatisfaction in the health care community. "I am pleased to announce modifications to OIG policies and practices that are responsive to concerns that we have heard from the provider and enforcement community regarding the civil settlement process," she says.

"The OIG and the Department of Justice will continue to seek to resolve a provider’s permissive exclusion liability concurrently with its False Claim Act liability. However, we recognize there may be a limited number of cases where it would be appropriate to resolve a provider’s permissive exclusion liability separately or subsequent to resolution of the False Claims Act case," Rehnquist writes. "We also recognize that in certain cases it may be appropriate to release the OIG’s administrative exclusion authorities without a corporate integrity agreement."

Rehnquist says she has directed her staff to consider the following criteria when determining whether to require a CIA, and, if so, the substance of that agreement: 1) whether the provider self-disclosed the alleged misconduct; 2) the monetary damage to the Federal health care programs; 3) whether the case involves successor liability; 4) whether the provider is still participating in the Federal health care programs or in the line of business that gave rise to the fraudulent conduct; 5) whether the alleged conduct is capable of repetition; 6) the age of the conduct; 7) whether the provider has an effective compliance program and would agree to limited compliance or integrity measures and would annually certify such compliance to the OIG; and 8) other circumstances, as appropriate.

Rehnquist also says she is concerned about the financial impact of CIAs on providers. To address this concern, the OIG is modifying the provisions of CIAs that address billing reviews and the use of independent review organizations to reduce their financial impact without weakening the integrity of a provider’s compliance program. Specifically, the CIA billing review requirements will, in the future, require the use of a full statistically valid random sample only in instances where the initial claims review (which we will call a discovery sample) identifies an unacceptably high error rate.

The OIG will be reviewing each provider’s CIA to determine whether it is appropriate to incorporate the new claims review procedures