The Role of IG In 2003, the 78th Texas Legislature created the Office of Inspector General to strengthen the Health and Human Services Commission's (HHSC) capacity to combat fraud, waste, and abuse in publicly funded state-run Health and Human Services programs. The Inspector General's (IG) mission, as prescribed by statute, is the "prevention, detection, audit, inspection, review, and investigation of fraud, waste, and abuse in the provision and delivery of all health and human services in the state, including services through any state-administered health or human services program that is wholly or partly federally funded, and the enforcement of state law relating to the provision of these services." IG's primary tools for detecting, …show more content…
531.102 creates the IG, and gives the IG the responsibility to investigate fraud, waste, and abuse in the provision and delivery of all health and human services in the state, including services through any state-administered health or human services program that is wholly or partly federally funded, and the enforcement of state law relating to the provision of those services. Sec. 531.102(a-5) and (a-6) requires the IG to conduct investigations independent of the executive commissioner and the commission but asks that the IG closely coordinate with the executive commissioner and the relevant staff of health and human services system programs that the office oversees in performing functions relating to the prevention of fraud, waste, and abuse in the delivery of health and human services and the enforcement of state law relating to the provision of those services. Sec. 531.102 (f-1) requires the IG to complete a full investigation of a complaint or allegation of Medicaid fraud or abuse against a provider not later than the 180th day after the date the full investigation begins unless the office determines that more time is needed to complete the …show more content…
Section 531.102(s) also recognizes the IG's authority to utilize a peer-reviewed sampling and extrapolation process when auditing provider records. MPI INVESTIGATIONS UNIVERSE The Medicaid Provider Integrity (MPI) Investigations Division defines its investigations universe as the departments, programs, functions, and processes within the Health and Human Services (HHS) System, including services delivered through managed care, and services delivered through providers and contractors. Managed Care Managed Care Entities and
Phase I addressed basic statutory definitions, general prohibitions, and explanations of what constitutes a financial relationship between a physician and a health care entities providing DHS’. Phase II deals with the regulatory exceptions, reporting requirements, and public comments pertaining to Phase I. Finally, Phase III Final Regulations were published in September of 2007, and largely addressed comments made after publication of the Phase II rules and regulations. It also reduced some of the regulations placed upon the healthcare industry by explaining and modifying some of the exceptions related to financial relationships between physicians and DHS entities where there is minimal risk of abuse to the patient, Medicare or Medicaid.
...imited – FAI was implementing detrimental provisioning practices, including among others failure to monitor claims lower than $100,000 and lack of clear methodology on how claims estimates were monitored. These reports were made in 1997, a year before HIH announced its proposed takeover of FAI in September of 1998.
Under the Social Security Act, it is required that hospitals report quality measures for a set of 10 indicators. If hospitals do not report quality measures to CMS there is a reduction in payments. In the hospital readmission area of investigation, OIG reviews Medicare claims in hospital readmission cases to identify trends and oversights of cases. Readmissions are cases in which the beneficiary is readmitted to the hospital less than 31 days after being discharged from the hospital. Hospitals are only entitled to one diagnosed-related group payment if there is a same-day readmission for symptoms related to prior hospital stay. Quality improvement organizations are required to review hospital readmission cases also this is to see if standard of care are met. For coded conditions as present on admission, it is required for acute hospital to report these diagnoses on Medicare claims. The OIG will review Medicare claims for types of facility or providers most frequently transferring patients to hospital
The SOX act section 404 requires that the auditor assess the company’s management of internal controls and report on it. The act requires that a company include a copy of the internal controls in the year end annual report. All financial statements must be certified by a company’s management. (Coustan, 2004)
Some federal statutes address fraud in government health care programs, and many of these laws vary considerably (Krause 2004). Some of these laws specifically target health care fraud. Example of the laws that the government direct at inappropriate health care activities includes the “Medicare and Medicaid Anti-Kickback Statute and Ethics in Patient Referrals Act (EPRA).”
Due to lack of money it is impossible for agencies to investigate every person and business for compliance with the law. The agencies have to go through and select the ones they can with the funds they have and investigate them. Because of the budget and certain hindrances and the expense and inconvenience of being able to enforce the law especially if there is a breach this contributes to the difficulty of being able to investigate. The administrators are generally granted the discretion to choose who should be investigated for a violation. There is only certain exception where a party who is subject to be investigated can object by claiming selective prosecution.
In December 2011, Texas Health and Human Services Commission (HHSC) received federal approval of a Medicaid Section 1115(a) Demonstration Waiver, entitled “Texas Healthcare Transformation and Quality Improvement Program,” for the period starting with December 12, 2011 through September 20, 2016. The main objective of the 1115 Waiver is to improve access to and quality of health care by expanding Medicaid managed care programs and promoting health care delivery system reforms while containing cost growth. Specifically, the Waiver created two new pools of funding—Uncompensated Care (UC) and Delivery System Redesign and Innovation Payment (DSRIP) pools—by redirecting funds that were available under the old Upper Payment Limit (UPL) payment methodology. DSRIP funding is used to offer financial incentives to health care providers that develop and implement projects aimed at improving how care is delivered to low-income populations. Specifically, the providers (often referred to as the “performing providers” or “performers”) propose and execute projects like programs, strategies, and investments designed to enhance access to health care, quality of health care, cost-effectiveness of services, and health of the patients and families served.
How your medical information is used and disclosed must now be given to you. The notice must also tell you how to exercise your rights and how to file a complaint with your health care provider and with the DHHS Office of Civil Rights.
However, beyond these important components, there are regulatory agencies that govern and grant a hospital the right to operate and require the hospital to remain compliant with their rules. Some of these agencies and laws are the Centers for Medicare and Medicaid Services (CMS), the Joint Commission (TJC), the Health Insurance Portability and Accountability Act (HIPAA), the Emergency Medical Treatment and Active Labor Act (EMTALA), and individual state laws. According to Shannon (2010), each of these laws and regulatory bodies has unique and specific requirements the hospital must meet to either participate in a benefit of the agency or in some cases, the right to remain doing business. Many of the agencies use in-person site surveys and inspections to monitor compliance. Furthermore, liability insurance companies, including those covering malpractice, usually require a formal risk management plan be in
In conclusion, managed care integrates the functions of financing, insurance, delivery, and payment within an organization. It also exercises formal control over utilization. Managed care is viewed as accepting the lowest competitive bid for services rendered. Today, HMOs and PPOs are the most common and widely used models for managed care. Although managed care is here to stay, it requires revision in some areas. Challenges that are to be faced include double agentry, fidelity, confidentiality, honesty, and vulnerability. With the help and guidance of health information professionals, managed care will continue to escalade and become better for all.
Health care fraud is an ever growing problem with in our country. This is not a new issue, nor an issue that will ever go way. According to the Federal Bureau of Investigations (FBI) health care fraud cost tax payers two hundred and seventy two billion dollars in 2013 (Federal Bureau of Investigations, 2016). The numbers have continued to increase. When discussing health care fraud we need to know what exactly we are discussing.
Pozgar, G.D. (2012). Legal Aspects of Health Care Administration. United States of America: Jones and Bartlett Learning, LLC.
The purpose of quality initiatives is to promote safe, timely, effective, efficient, equitable patient centered care( DeNisco & Barker, 2013). The quality improvement evaluation is important in the health care industry to find out the best practice care and to provide high quality cost effective care to patients. The public and private agencies are the regulatory entities in the health care Industry which promote quality and safety in the delivery of health care. The major regulatory agencies are CMS, the Joint commission, and AHRQ (deNisco & Barker, 2013).
...gram polices and laws that have been put in place by OIG are making an impact with tracking fraudulent providers and claims. Claims need to be reviewed to ensure each claims are before they are paid, to ensure money is not being wasted. Fraud and Abuse will remain a problem unless the government cracks down on providers.
The part of the unit known as the internal affairs department is under the inspection unit section. The main job of an internal affairs investigator entails keeping a close eye on department’s policies and procedures by conducting “internal quality control inspections” (Dempsey, Frost, & Carter, 2014) (p. 99). Other duties that one must consider when working in this area of the unit according to (Dempsey, Frost, & Carter, 2014) is to focus on suspected “misconduct and corruption of other officers” (p. 99). They must ensure that all employees within the department are adhering to the rules and conducting themselves in the manner that the system, guidelines and policies requires. Another main objective that the internal affairs division has is to uphold the integrity of the department. In fact, according to (Dempsey, Frost, & Carter, 2014), “they are the police that police the department” (p. 247).They do so by making any improvements and putting new practices into practice and making sure officers are abiding in those protocols and