On January 31, 2005, the HHS Office of Inspector General (OIG) issued new hospital compliance guidance that alerts all hospitals, including NYU Medical Center, to the fact that they are expected to play an active role in preventing, detecting, and correcting fraud and abuse. The 2005 guidance, which builds on the OIG’s previous (1998) hospital guidance, describes the eight major areas that the government considers to be at particular risk for fraud and abuse. (See links below.) Within these eight broad areas there are many specific regulations that are “currently of concern to the enforcement community.”

Topping the list of fraud and abuse areas is the submission of accurate claims and information. “Perhaps the single biggest risk area for hospitals is the submission of claims and other requests for payment from the Federal health care programs.” Hospitals are cautioned that they must disclose and return any overpayments that result from mistaken or erroneous claims, and reminded that they are liable under the False Claims Act, which carries heavy penalties.

• Submission of Accurate Claims and Information
• The Referral Statutes: The Physician Self-Referral Law (Stark Law) and Federal Anti-Kickback Statute
• Payments to Reduce or Limit Services
• Emergency Medical Treatment and Labor Act (EMTALA)
• Substandard Care
• Relationship with Federal Health Care Beneficiaries
• HIPAA Privacy and Security Rules
• Billing Medicare or Medicaid Substantially in Excess of Usual Charge

They have also identified some key topics that have generated a number of inquiries from hospitals:

General Interest Topics

• Discounts to Uninsured Patients
• Preventive Care Services
• Professional Courtesy

Hospital Compliance Program Effectiveness

Key elements of Compliance program effectiveness include:

• Code of Conduct
• Regular Review of Compliance Program Effectiveness
• Development of Compliance Policies and Procedures—including Standards of Conduct
• Developing Open Lines of Communication
• Appropriate Training and Education
• Internal Monitoring and Auditing
• Response to Detected Deficiencies
• Enforcement of Disciplinary Standards
• Self Reporting

Conclusion

In today’s environment of increased scrutiny of corporate conduct and increasingly large expenditures for health care, it is imperative for hospitals to establish and maintain effective compliance programs. These programs should foster a culture of compliance that begins at the highest levels and extends throughout the organization. This supplemental CPG is intended as a resource for hospitals to help them operate effective compliance programs that decrease errors, fraud, and abuse and increase compliance with Federal health care program requirements for the benefit of the hospitals and public alike. Dated: May 20, 2004. Lewis Morris, Chief Counsel to the Inspector General. [FR Doc. 04–12829 Filed 6–7–04; 8:45 am] BILLING CODE 4150–01–P