Compliance-conscious hospitals and health systems -- which pretty much should mean all of them -- could benefit from knowing what pushes federal investigators' buttons.
James Sheehan, head of the civil division at the U.S. attorney's office in Philadelphia, will discuss those red flags in his talk "Legal Compliance Strategies and Solutions" at 10 a.m. and 2 p.m. Monday, March 2, as part of the ACHE congress in Chicago.
The 1998 work plan for HHS' inspector general's office offers compliance officers a good road map, telling them where federal enforcers will be looking for fraud and abuse, Sheehan says.
One area Sheehan and other government prosecutors will continue to watch is DRG upcoding, particularly involving pneumonia cases.
Federal prosecutors also will be eyeing relationships between hospitals and their affiliated physicians. This encompasses physician ownership deals and hospitals' acquisition of physician practices.
Quality issues also are arising in some recent fraud and abuse cases, and Sheehan has pioneered the use of the False Claims Act to punish negligent providers.
"HMOs and hospitals are required to present length-of-stay information," Sheehan says. "If it differs by payer, that raises a red flag, and we have to look at that."
Sheehan also plans to talk about the questions he asks when hospitals take on a piece of the risk in managing care.
"You've got to make sure you don't do the bad things that some HMOs do," he says. "We will be looking at that very closely." In particular, Sheehan is referring to limiting treatment access, which tends to undermine quality of care.
The most vigilant providers typically have some sort of software oversight in place, Sheehan says.
"There's some commercial software out there that allows you to look at claims patterns and history," he says. "It can even allow you to do regular or annual sampling . . . which is highly recommended."