Medicare, Medicaid Fraud Self-Disclosure Protocol Tightening

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Medicare, Medicaid Fraud Self-Disclosure Protocol Tightening

Written by Stephanie Wasek

Friday, 18 April 2008

New requirements of initial self-disclosure of Medicare or Medicaid fraud have been issued by the Department of Health and Human Services Inspector General Daniel Levinson in an open letter. The fuller disclosure to the Office of Inspector General will be required if providers want to win the leniency provided for by the self-disclosure protocol.

To improve the disclosure process, the OIG has concluded that the initial submission must contain the following information in addition to the basic information described in the self-disclosure protocol:

1. a complete description of the conduct being disclosed;

2. a description of the provider's internal investigation or a commitment regarding when it will be completed;

3. an estimate of the damages to the Federal healthcare programs and the methodology used to calculate that figure or a commitment regarding when the provider will complete such estimate; and

4. a statement of the laws potentially violated by the conduct.

If the last two requirements cannot be provided at the time of initial disclosure, "the provider must be in a position to complete the investigation and damages assessment within 3 months after acceptance into the SDP."

Further, to ensure efficiency of the program, self-disclosure must report only matters that implicate "potential fraud against the Federal healthcare programs ? that potentially violate Federal criminal law, civil law or administrative laws." In other words, if the situation involves "merely an overpayment," writes Mr. Levinson, the billing errors or overpayments "should be submitted directly by the provider to the appropriate claims-processing entity, such as the Medicare contractor."