Healthcare Services

The External IRO…

The External IRO…

A Valuable Tool for the Compliance Officer’s Toolbox

By Kelly Bray, Esq., FHAS Compliance Officer

In March 2017, HHS-OIG released a resource guide for measuring compliance program effectiveness in response to the Justice Department’s list of common questions that any provider organization could face. While packed with guidance documents and over 100 pages of checklists and best practices, there is one invaluable recommendation not contained within the document: Using an External IRO for compliance auditing and provider billing practices and procedures.

In FY 2016, investigations conducted by HHS’ OIG resulted in 765 criminal actions that engaged in crimes related to Medicare and Medicaid, and 690 civil actions, which include false claims and unjust-enrichment lawsuits filed in federal district court, civil monetary penalties (CMP) settlements, and administrative recoveries related to provider self-disclosure matters.

With every CIA settlement, there are two critical mandates for providers that are essential to settlement: Enhance your compliance practices and utilize an external IRO. The two are intrinsically linked. When your compliance department enlists the help of an IRO to provide ongoing auditing of procedures and billing, they get external, independent reinforcement for their mission: to maintain effective compliance with all regulations and policies. In some companies, executives view compliance as something that is suffered instead of something that serves the company. With an external IRO, issues are identified more clearly with less undue pressures placed on the Compliance Officer. As declared by Thomas Jefferson in Lin Manuel Miranda’s Hamilton: “If there’s a fire you’re trying to douse, you can’t put it out from inside the house”.

The process an IRO uses to review procedures and billing practices doesn’t change whether occurring before or after a OIG investigation. What does change is the time, expense, and detriment to the company’s reputation that follows any DOJ-initiated litigation.

In the worst case scenario, you will find an error that triggers self-reporting to the OIG. However, self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a government-directed investigation.

With ever-changing regulations and policies, companies need to get ahead of the issues. A compliance department collaborating with an external IRO catalyzes companies to proactively shape solutions instead of simply reacting to crises.