At a luncheon meeting of the American Health Lawyers Association ("AHLA")
Fraud and Abuse Special Interest and Substantive Law Committee on Friday,
November 12, Kimberly Brandt of the Department of Health and Human Services
("DHHS"), Office of Inspector General ("OIG"), told attendees that OIG
intends to issue draft compliance guidance for physicians and small
practices sometime in 2000. OIG received eighty-three comments by the
November 8 closing date in response to its solicitation of information and
recommendations for developing such guidance published at 64 Fed. Reg. 48846
(Sept. 16, 1999) on whether such guidance would be helpful. One of those
comments was a reply to the request for information identifying key issues
for the OIG to consider in writing its guidance, drafted by Claire C. Obade,
Esq., and William H. Maruca, Esq., on behalf of AHLA's Model Physician
Compliance Task Force, which is developing a model physician compliance
manual. To read that document, click here
http://www.healthlawyers.org/docs/oigsuggest_modphyscomptf.pdf
Brandt told attendees that, along with the traditional seven elements common
to all of OIG's compliance guidance, OIG has tentatively identified the
following risk areas for physicians:
* Unbundling (e.g., billing multi-channel set of lab tests to appear
as if individual tests were performed);
* Soliciting, offering, or receiving a kickback, bribe, or rebate
(e.g., paying for a referral of patients, getting a kickback for ordering
diagnostic tests);
* Routine waiver of copays and deductibles, regardless of need;
* Billing for services not rendered ("no shows");
* Upcoming;
* Double-billing (Medicare and beneficiary/insurer);
* Billing for physician services rendered by non-physicians/teaching
physician requirements;
* Medical necessity (documentation to support);
* Misrepresenting diagnosis to justify services;
* Completing certificates of medical necessity for patients not
personally and professionally known by the physician;
* Billing Medicare/Medicaid for investigation research, medications,
and procedures without proper authorization; and
* Billing for a non-covered service as if covered.
OIG hopes to have the draft guidance out by February or March 2000, followed
by a comment period, with the final rule to be issued in early summer,
possibly by June 2000. She also stated that OIG will still accept and
evaluate comments for its consideration while working on the guidance,
although the comments will not be part of the formal process because the
comment period has already closed.
