The Office of Inspector General (OIG) settled multiple healthcare cases during the fourth quarter of fiscal year 2021. The settled cases begin the process of recovering funds for the State of Texas.
The OIG’s Litigation Team works with healthcare providers to resolve cases that are pending. The OIG worked with a Texas pediatric care provider that had been billing separately for audiometry services. Audiometry services are included as part of a component bundle for the Texas Health Steps, which is part of preventative care services. The pediatric provider fully participated with the OIG to identify the error and to fully understand proper billing procedures to prevent errors like this from recurring. The pediatric provider agreed to a $330,000 settlement.
Other cases included two different private duty nursing providers that improperly reimbursed more than the maximum allowable for certain clients. Both of these private duty nursing providers cooperated with the OIG and settled their cases. One of the providers agreed to pay $108,567 and the other $73,916.
Additionally, in July 2021, the OIG pursued a case that centered on allegations of Medicaid client solicitation and erroneous billing. The provider agreed to pay $50,000, which included $15,000 in penalties for violation of program rules, to settle the allegations. The provider had closed his practice in 2019, but was still able to work with the OIG to improve his understanding of applicable statutes and Texas Medicaid policies and provisions to prevent future errors.
Issue:
The Centers for Medicare & Medicaid Services (CMS) requires skilled nursing facilities to have a Compliance and Ethics Program that is effective in preventing and detecting criminal, civil, and administrative violations under the Social Security Act, and in promoting quality of care. Routine audits should be conducted on billing practices and all levels of monetary transactions, and the results of the audits should be reported to the Compliance and Ethics Committee and to the governing body. The audits should include a corrective action plan in the case that a discrepancy is found, and all discrepancies should be investigated and rectified immediately. It is imperative that every facility have an effective Compliance and Ethics Committee to reduce the likelihood of healthcare fraud, waste, and abuse of government funds.
Discussion Points:
- Review your policies and procedures for operating an effective Compliance and Ethics Program. Ensure that your policies are reviewed at least annually and updated when new information becomes available.
- Train all staff on your compliance and ethics policies and procedures upon hire and at least annually. Document that these trainings occurred and file the signed document in each employee’s education file.
- Periodically perform audits to ensure all staff are aware of compliance and ethics requirements and understand their responsibility to report any concerns of compliance and ethics violations to their supervisor, the compliance officer, or via the anonymous hotline.
