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Why do we need a compliance program?
Federal Sentencing Guidelines involving an organization (medical practice)
The critical need for an outside billing auditor
Effective Compliance Programs
Criminal liability can attach to an organization whenever an employee of the organization commits an act within the apparent scope of his or her employment, even if the employee acted directly contrary to company policy and instructions. An entire organization, despite its best efforts to prevent wrongdoing in its ranks, can still be held criminally liable for any of its employees’ illegal actions.
Consequently, when the Sentencing Guidelines Commission promulgated the organizational guidelines, it attempted to alleviate the harshest aspects of this institutional vulnerability by incorporating into the sentencing structure the preventive and deterrent aspects of systematic compliance programs. The Commission did this by mitigating the potential fine range - in some cases up to 95 percent - if an organization can demonstrate that it had put in place an effective compliance program.*
(*An Overview of the Organizational Guidelines, Paula Desio, Deputy General Counsel, United States Sentencing Commission)
It is also required by the Federal Sentencing Guidelines. As a reminder, each false claim by you biller subjects you to a $5500 to $11,000 fine per event.
The critical need for an outside billing auditor
Federal Sentencing Guidelines involving an organization (medical practice)
The critical need for an outside billing auditor
Those of you who have a medical practice must understand that there are several critical elements of a comprehensive compliance program. Implementing only an auditing component is not sufficient to satisfy the government's requirements.
That understood, the most essential single element is a comprehensive outside auditing program of claims billing.
The billing of Department of Labor claims is difficult and complex. Our auditors are experienced in the requirements of appropriate documentation of claims. A claim that is not sufficiently documented is considered a false claim.
Some practices believe that if they underbill a particular code they are safe from inappropriate billing. This is not the case. Underbilling a claim is also a false claim. The government believes that if a practice does this, they are providing an improper inducement for patients or businesses to return to the practice.
Federal Sentencing Guidelines involving an organization (medical practice)
Federal Sentencing Guidelines involving an organization (medical practice)
Federal Sentencing Guidelines involving an organization (medical practice)
CHAPTER EIGHT - SENTENCING OF ORGANIZATIONS
Introductory Commentary
The guidelines and policy statements in this chapter apply when the convicted defendant is an organization. Organizations can act only through agents and, under federal criminal law, and generally they are vicariously liable for offenses committed by their agents. At the same time, individual agents are responsible for their own criminal conduct. Federal prosecutions of organizations therefore frequently involve individual and organizational co-defendants. Convicted individual agents of organizations are sentenced in accordance with the guidelines and policy statements in the preceding chapters. This chapter is designed so that the sanctions imposed upon organizations and their agents, taken together, will provide just punishment, adequate deterrence, and incentives for organizations to maintain internal mechanisms for preventing, detecting, and reporting criminal conduct.
Fraud in Federal Insurance Programs
How we can guide you away from the pitfalls of medical compliance
Federal Sentencing Guidelines involving an organization (medical practice)
Government estimates that approximately 10% of the total US health care expenditures are fraudulent
More than $100 billion annually is extent of health care fraud
DOJ- health care fraud # 2 priority after violent crime
False Claims Act (FCA) empowers government to investigate and bring civil action in fraud cases
What organizations do to make matters worse
How we can guide you away from the pitfalls of medical compliance
How we can guide you away from the pitfalls of medical compliance
Four aggravating factors that adds to a practice's culpability
1. If an individual that was high level personnel “participated in, condoned or was willfully ignorant of the offense”
2. If the violation is a repeat offense
3. If the government was hindered during its investigations and
4. if awareness of and tolerance of the violation were pervasive
How we can guide you away from the pitfalls of medical compliance
How we can guide you away from the pitfalls of medical compliance
How we can guide you away from the pitfalls of medical compliance
Four factors that help mitigate an organizations culpability :
1. If the organization had an effective compliance program, even though there was a violation
2. If the organization reported the violation promptly
3. If the organization cooperated with the government investigators
4. If the organization accepted responsibility for the violation
These factors can have a profound effect on the amount of a fine