Proposed Exclusion Authority Rule
The proposed
Exclusion Rule would significantly expand the exclusion regulations to persons
or entities that receive funds from federal health care programs. The Exclusion
Rule provides for the following three new permissive exclusions:
·
Conviction
of an offense in connection with obstruction of an audit;
·
Failure
to supply payment information, including when ordering, referring for
furnishing, or certifying the need for items or services; and
·
Making,
or causing to be made, any false statement, omission, or misrepresentation of a
material fact in applications to participate as a provider of services or
supplier under a Federal health care program.
The Exclusion Rule
further provides details for when and how the CMPs are applied, the method for
calculating such payments, and the liability guidelines under the OIG.
Proposed Civil Monetary Penalties Update
The proposed CMP
Rule would codify five new penalties, assessments, and exclusions, as stated
below:
·
Timely
access to records not granted to the OIG;
·
Ordering
or prescribing covered services while excluded from a Federal program;
·
Making
false statements, omissions, or misrepresentations in an enrollment
application;
·
Failure
to report and return overpayments; and
·
Making
or using a false record or statement that is material to a false or fraudulent
claim.
These proposed
changes further the government’s focus under the Affordable Care Act to
strengthen fraud and abuse regulations and increase funding to deter fraud. For
example, the proposed rule provides that CMPs may be assessed ranging from
$10,000 per improper claim to $50,000 for each improper violation of the AKS.
Further, the CMP Rule defaults to a penalty of $10,000 for each day for not
timely reporting and returning an identified overpayment.
Organizations need
to ensure that their compliance processes are in place for the finalization of
these rules. This includes adequately
assessing processes and procedures to ensure your organization can effectively
monitor any issues covered under these rules.
For additional
information related to compliance
concerns or these proposed rules, please feel free to contact Susan E. Ziel at (317) 238-6244 or Alex
T. Krouse at (574) 485-2003.