The Office of Inspector General (OIG): Fraud and Abuse

When medical billing and coding professionals speak of the Office of Inspector General (OIG), it is usually in reference to a possible audit or a compliance program. Most likely it is also related to the Medicare and Medicaid programs or the Health Insurance Portability and Accountability Act (HIPAA).

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Although there are OIGs for many federal cabinet-level departments, in the medical billing and coding world OIG is referring to the Office of Inspector General for the Department of Health and Human Services (DHHS). Following the chain of command down, DHHS is the department which oversees the Centers for Medicare and Medicaid Services (CMS), which in turn manages these namesake programs as well as certain HIPAA violations. That being said, the OIG can become involved when it suspects fraud, abuse, or waste in any of the departments from DHHS down.

To make it easier for medical billing and coding professionals to stay within federal operating guidelines, the OIG has released a memorandum on compliance program guidance specifically for third-party medical billing and coding professionals. The OIG provides a basic template for billing and coding professionals to follow and therefore avoid any legal trouble associated with fraud and abuse in the Medicare and Medicaid programs. Although following the OIG’s recommendation is not required by law, it is no doubt one of the surest ways to avoid fines and prosecution. The OIG’s compliance program guidance has been developed with the Department of Justice (the department responsible for the prosecution of fraud and abuse) and other key players in the health care industry.

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Billing and coding professionals can adapt these OIG suggestions to their own private practice, a small business, or a large company. The following seven recommended compliance program steps are provided by the OIG, and directly based on Federal Sentencing Guidelines to punish those convicted of federal crimes:

1. Develop and circulate a written document that covers standards of conduct and specifically addresses the potential of fraud in vulnerable areas such as:

  • Claims submissions
  • Over billing
  • Inappropriate financial relationships between billing and coding professionals with health care providers

2. Designate someone who is in charge of monitoring and operating these standards of conduct in this compliance program.

3. Make sure to conduct team or individual training sessions that keep all necessary employees up to date on the most current developments with the OIG.

4. Create and maintain a way of receiving tips or reports regarding any violations of the standards of conduct. Make sure those providing information can do so anonymously.

5. Develop a response plan to investigate reports of violations of the standards of conduct. Accordingly, develop a response plan to punish violators.

6. Ensure that all are in compliance with the standards of conduct. This can be done by conducting periodic audits or other risk evaluation techniques.

7. When violators or problems with the standards of conduct have been identified, take the appropriate action to correct these. In the case of violators, this should include the option of loss of employment.

The OIG provides this information knowing that the health care and medical billing and coding industries are constantly changing and evolving. It also understands that medical billing and coding professionals can work in a one-person business or a large national company. However the OIG maintains that implementing this basic seven-step template can drastically reduce any legal problems that one may encounter because of fraud and abuse in a program overseen by the OIG of the DHHS.