Three Key Players
HCR 460: Investigations and Disclosures in Health Care Compliance
The three key players in the healthcare regulatory and enforcement process I will be discussing today are the OIG, CMS, and HHS. The OIG was established in 1976 to investigate fraud, abuse, and waste (OIG. Nd). This is to ensure that Medicaid and Medicare are running smoothly without any fraud and abuse issues (OIG. Nd). The Centers for Medicare and Medicaid Services (CMS) was signed into law by President Lyndon B. Johnson on July 30, 1965. CMS was created to give insurance coverage for the disabled, people 65 or older, and people with ESRD who require dialysis or a kidney transplant (CMS. 2023). The U.S. Department of Human and Health Services was created to ensure that all Americans are able to receive effective health and human services that provide adequate healthcare (HHS. 2023).
The two advantages I want to point out from the OIG’s Self-Disclosure Protocol are first, reporting helps have the OIG investigate unethical and illegal activities happening within a company (OIG. 2021). Secondly, internal processes tend to take less time when people agree to a self-disclosure protocol (OIG. 2021). A disadvantage of the self-disclosure protocol is the eligibility criteria for using the SDP (OIG. 2021). The disadvantage to this is only specific areas of the healthcare system such as healthcare providers, suppliers, or others who are part of the OIG’s CMP authorities cannot use the OIG SDP (OIG. 2021). However, anyone who is part of a government inquiry is not part of the ineligible list (OIG. 2021).
The ten guiding rules are needed to know, control, and track information, fully debrief complainants, chain of custody, be fair and impartial, include management’s view, exercise discretion, stay focused and flexible, be comprehensive, and prevent retaliation (Kusserow. N.d.). The need-to-know basis should only consist of what needs to be talked about and not about how things may or may not turn out (Kusserow. N.d.). The control and track information is keeping up on all reports via hotlines and they should be logged and dated (Kusserow. N.d.). The chain of custody is tracking evidence that is collected during the investigation (Kusserow. N.d.). Being fair and impartial is when the investigator is being impartial to the point that fairness is involved when collecting and reviewing all facts that are relevant to the case (Kusserow. N.d.).
Including the management’s view is only part of the report and not the investigation itself (Kusserow. N.d.). Exercising discretion is extremely important when it comes to being an investigator and investigating because you don’t want to risk information getting out and taking the case (Kusserow. N.d.). Staying focused and flexible means the investigator must stay focused and not lose track of the case and being flexible means having no conflict when it comes to investigating (Kusserow. N.d.). Being comprehensive is to ensure everything is done right the first time because one mistake can ruin the investigator’s entire case (Kusserow. N.d.). Lastly, preventing retaliation is important to ensure future whistleblowers feel safe in reporting illegal and unethical activities because patient care needs ethics and legal liability. (Kusserow. N.d.).
Resource
· Office of Inspector General (OIG). N.d. About OIG. Retrieved from https://oig.hhs.gov/about-oig/
· CMS. 2023, September 06. History. Retrieved from https://www.cms.gov/about-cms/who-we-are/history
· HHS. 2023, August 31. About HHS. Retrieved from https://www.hhs.gov/about/index.html
· OIG. 2021, November 08. OIG’s Health Care Fraud Self-Disclosure Protocol. Retrieved from https://oig.hhs.gov/documents/self-disclosure-info/1006/Self-Disclosure-Protocol-2021.pdf
· Richard Kusserow. N.d. Conducting Internal Investigations in Healthcare Compliance Using Ten Guiding Rules. Retrieved from https://www.compliance.com/wp-content/uploads/2019/09/Conducting-Internal-Investigations-Using-Ten-Guiding-Rules_RPK.pdf
