Compliance Perspective:
The Compliance Officer should periodically together with the Risk Manager review the facility’s policies and procedures for contracting with vendors and check to ensure that all contracts have been duly signed and are on file. Prior to validating a vendor contract and accepting the services they are to provide, the Compliance Officer should verify with the Administrator that the vendor’s background has been checked, that the vendor is not on the OIG Exclusion List, has not been sanctioned and is certified to participate in Medicare, Medicaid or other applicable reimbursement programs. The facility may want to periodically schedule educational group meetings for residents and family members to answer questions they may have about statements they receive from reimbursement programs. This could provide an opportunity for those attending to learn how to report suspicious claims for things like services not provided. An audit should be performed on an annual basis to verify that vendors providing services,
equipment or supplies to the facility have not been excluded or sanctioned by the OIG.
U.S. Attorney’s Office recently announced a $1.2 million settlement with a Florida ambulance company to resolve allegations that the ambulance company over a period of almost 11 years from June 29, 2005, to January 2016. The company knowingly up-coded claims it submitted for life support services. Instead of classifying claims as “Basic”, the company designated them as “Advanced” without any justification. They also submitted claims for unnecessarily transporting patients and claiming the need for using emergency status for just transporting patients to their homes. The settlement is the result of a multiple-year investigation and the government’s intervention into a whistleblower suit in 2015.
The settlement involved false claims submitted to Medicare, TRICARE, Medicaid and Federal Employees Health Benefits Program managed by the Office of Personnel Management. The case was initiated by the filing of a qui tam lawsuit filed by a former employee of the ambulance company.
