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Healthcare Provider Self-Disclosures in 2018 Resulted in $73 Million

In 2018, providers self-disclosed and settled with the Department of Health and Human Services (HHS) Office of Inspector General (OIG) for a total amount of $73,274,524.1 An analysis of the 2018 settlements appears to indicate that a thorough evaluation of well-established controls is needed as known issues are the root cause in a majority of the settlements.

The provider self-disclosure settlements in 2018 consisted of issues in four areas:

  1. Claims, Coding, Billing Requirements (44%)
  2. Employment of Excluded Individuals (30%)
  3. Self-Referrals/Kickbacks (15%)
  4. Unlicensed or Non-Credentialed Staff (11%)

Claims, Coding, and Billing Requirements. The top reason that necessitated providers having to self-disclose were issues related to claims, coding, and billing requirements. Many of these were likely due to internal audits and reviews revealing a lack of medical necessity in the medical records. While some self-disclosures were prompted by the more complex and detailed billing requirements not having been met, there were quite a few self-disclosures regarding the incident-to-services and supervising requirements. These involved the usual nurse practitioners, physical therapists, and technicians. Providers would be well advised to spend additional resources on the front end to catch these issues before they turn into self-disclosures. In 2018, individual settlements on these types of claim and billing requirements ranged from $10,000 to $12.7 million and totaled $41.9 million.

Employment of Excluded Individuals. For those of us who do not directly work in human resources, it may be surprising to see that 30% of the 2018 self-disclosures were the result of having employed an individual that the provider knew or should have known was excluded from participation in Federal health care programs. While many health care employers have made screening against the exclusion lists a basic requirement in their hiring processes, it is evident that missing even one employee can have serious consequences. The types of employers impacted varied from large and small hospitals, dialysis centers, clinics, rehabilitation service providers, and medical groups. This variety in the types of employers demonstrates that no one type of employer was more susceptible than another to this issue. In 2018, individual settlements for having employed an excluded individual ranged from $10,000 to $671,461 and totaled $3.2 million.

Self-Referrals/Kickback. The next category of self-disclosures concerned physician self-referrals and kickbacks. Again no newly discovered issues here, the self-disclosures were in regards to leases (equipment and office space), medical directorships, excessive compensation from inflated salary and incentives, and management company fees. In 2018, individual settlements for physician self-referrals and kickbacks ranged from $10,000 to $8.2 million and totaled $25.7 million.

Unlicensed or Non-Credentialed Staff. In 2018, providers self-disclosed that they had submitted claims by unlicensed or non-credentialed staff (e.g. nurses, physical therapists, dentists, emergency medical technicians). From experience the root cause of this issue is not during initial hire, but an oversight into the annual maintenance of licenses and credentials for these types of licensed medical professionals. In 2018, individual settlements from self-disclosing unlicensed or non-credentialed staff ranged from $10,000 to $1.3 million and totaled $2.3 million.


About the Author

Mai Lee Yang is a health care attorney in DeWitt’s Minneapolis office. Mai Lee focuses her practice on assisting with health care compliance and transaction matters. She advises health care companies, insurance, health plans, providers, durable medical equipment manufacturers, clinical laboratories, nonprofits, government entities, nursing homes, assisted living facilities, and other long-term care providers on responding to issues as well as proactively structuring and monitoring their business practices. If you have health care questions, you can reach Mai Lee by email or at (612) 305-1541.


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