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    7/29/2020 0

    Fraud, Waste, and Abuse

    Developing an Effective Compliance Program in Office Practice

  • 1

    Program speaker Today’s speaker is Arlene Luu, RN, BSN, JD, CPHRM, Senior Patient

    Safety & Risk Consultant, MedPro Group (

    Arlene provides comprehensive risk management services to insureds in MedPro

    Group’s Western Division. She has more than 20 years of experience as a

    registered nurse, and she has worked as a defense attorney representing

    doctors, nurses, nursing homes, and other healthcare providers in medical

    malpractice cases.

    Arlene’s experience in risk management and patient safety includes

    working in the hospital setting and providing risk consulting services to

    physicians in all specialties, dental providers, medical groups, and healthcare facilities. She has presented

    and published information on various patient safety topics, and she has provided risk management

    guidance and support related to healthcare law, quality improvement, and risk exposure.

    Arlene earned her bachelor of science degree in nursing from San Diego State University, a certificate in

    public health nursing for the state of California, and her juris doctorate degree from California Western

    School of Law. She is a licensed attorney in California and a certified professional in healthcare risk

    management (CPHRM).

  • 2

    Designation of continuing education credit MedPro Group is accredited by the Accreditation Council for Continuing Medical

    Education (ACCME) to provide continuing medical education for physicians.

    MedPro Group designates this enduring activity for a maximum of 1.0 AMA PRA

    Category 1 Credits™. Physicians should claim only the credit commensurate with

    the extent of their participation in the activity.

    MedPro Group is designated as an Approved PACE Program Provider by the

    Academy of General Dentistry. The formal continuing dental education programs

    of this program provider are accepted by AGD for Fellowship/Mastership and

    membership maintenance credit. Approval does not imply acceptance by a state

    or provincial board of dentistry or AGD endorsement. The current term of

    approval extends from October 1, 2018 to September 30, 2022. Provider ID#


    MedPro Group designates this continuing dental education activity as meeting the

    criteria for up to 1 hour of continuing education credit. Doctors should claim only

    those hours actually spent in the activity.

  • 3


    MedPro Group receives no commercial support from pharmaceutical companies,

    biomedical device manufacturers, or any commercial interest.

    It is the policy of MedPro Group to require that all parties in a position to

    influence the content of this activity disclose the existence of any relevant

    financial relationship with any commercial interest.

    When there are relevant financial relationships, the individual(s) will be listed

    by name, along with the name of the commercial interest with which the person

    has a relationship and the nature of the relationship.

    Today’s faculty as well as CE planners, content developers, reviewers, editors,

    and Patient Safety & Risk Solutions staff at MedPro Group have reported that

    they have no relevant financial relationships with any commercial interests.

  • 4

    At the conclusion of this program, the participant should be able to:

    Demonstrate understanding of the laws pertaining to fraud, abuse, and waste

    Understand the seven fundamental elements of an effective compliance

    program as defined by the U.S. Department of Health and Human

    Services, Office of Inspector General (HHS-OIG)

    Describe the key roles and responsibilities of a

    compliance officer

    Identify resources to assist in developing a

    compliance program for a healthcare practice



  • 5

    Fraud and abuse headlines

    Source: Department of Justice, U.S. Attorney’s Office, Northern District of Georgia. (2019, February 6.) Union General Hospital to pay $5 million to resolve alleged False Claims

    Act violations (Press Release). Retrieved from

    “It is unacceptable for hospitals

    to provide financial incentives to

    induce physicians to steer

    patients their way . . . The OIG

    will vigorously pursue providers

    who enter into arrangements

    that can potentially corrupt

    medical decision making.”

  • 6


    Fraud: Intentional deception or misrepresentation made by a person with knowledge that the deception could result in an unauthorized benefit to the person or others

    Abuse: When healthcare providers or suppliers perform actions that directly or indirectly result in unnecessary costs to any healthcare benefit program

    Waste: Inappropriate or inefficient use of resources

  • 7

    What is a compliance program? A corporate compliance program is an “effective program to prevent and

    detect violations of law.” — United States Sentencing Commission

    Prevents potential liability and/or

    sanctions to an entity

    Defines expectations

    for employees

    Demonstrates the

    organizational commitment to doing the right thing

    Provides a mechanism

    for monitoring

    Encourages reporting of unethical or

    illegal activities

    Source: United States Sentencing Commission. (2015, November). Guidelines Manual. Retrieved from


  • 8

    Compliance programs are a requirement under the

    Patient Protection and Affordable Care Act (ACA).

    Why have a compliance program?

    Source: Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 et seq. (2010).

  • 9

    Office of Inspector General (OIG) role

    Protect the integrity of HHS by preventing waste,

    fraud, and abuse in federally funded healthcare


    Offer voluntary compliance program tools and

    resources to help providers and suppliers avoid

    fraudulent conduct and prevent the submission of

    false claims.


    Source: U.S. Department of Health and Human Services, Office of Inspector General. (n.d.). About us. Retrieved from

    In 2000, HHS-OIG published Compliance Program Guidance for

    Individual and Small Group Physician Practices.

  • 10

    HHS-OIG: A good investment

    Source: U.S. Department of Health and Human Services, Office of Inspector General. (n.d.). Videos. Retrieved from

    In 2018, for every $1 we spent fighting healthcare fraud, we returned $4 to the federal government.

    Our 1,600+ employees oversee more than $1 trillion spent for the health and well-being of Americans.

  • 11

    HHS-OIG and the Affordable Care Act

    Seven elements of 2010 U.S. Sentencing Commission Guidelines Manual can be used as core compliance program elements.

    Affordable Care Act authorizes the Secretary of HHS in consultation with OIG to establish elements of a compliance program.

    An effective program can minimize consequences resulting from a violation of the law.

    Significant reductions in fraud and abuse liability can be accomplished through the use of compliance programs.

  • 12

    Federal sentencing guidelines

    Source: United States Sentencing Commission. (2018, November). Guidelines Manual. Retrieved from


    The United States Sentencing

    Commission (USSC) Guidelines

    Manual sets forth rules for a

    uniform sentencing policy for

    individuals and organizations

    convicted of felonies and serious

    (Class A) misdemeanors in the U.S.

    federal court system.

  • 13

    The overall goal of an effective compliance program is to create an ethical corporate culture.

    An ethical corporate culture reduces the chance that fraud and abuse will occur.

    If fraud and abuse do occur, an effective compliance program reduces the chance that it will go undetected.

    Creating an ethical culture

  • 14

    HHS-OIG hotline: 800-HHS-TIPS

    Recovery Audit Contractor (RAC)

    The False Claims Act whistleblower provision

    Beneficiaries, Explanation of Benefits (EOB), and publications

    Self-disclosure for a pattern of activity

    State and fed