HHS' inspector general's office has put into practice new guidelines for Medicare billing investigations that could help hospitals escape allegations of false claims.
The guidelines on the use of the federal False Claims Act are being applied to three areas of hospital billing nationwide.
The guidelines, released last summer, are significant because they establish a minimum threshold for deciding whether billing errors are subject to enforcement under the False Claims Act or should be referred to a provider's fiscal intermediary for collection of the overpayment.
At the American Hospital Association's annual meeting in Washington earlier this month, the AHA announced that the guidelines were being applied and released a memo it had received from the inspector general's office.
The memo said the guidelines are being applied to these three areas:
* Medicare overpayments caused by improperly coded hospital discharges.
* Medicare billing for pneumonia using a higher-paying DRG than is warranted.
* Separate billing for laboratory tests that should have been billed collectively.
While hailing the guidelines as a positive step, the AHA would like to know the government's minimum threshold for enforcement in each of the areas.
Without that information, the AHA can't know if the inspector general's office is following the guidelines, said Mary Grealy, senior Washington counsel for the AHA.
But the threshold levels won't be released "to preserve the integrity of the investigations and to avoid circumvention of the law," according to the inspector general's memo.
The thresholds have succeeded in narrowing some investigations, and hospitals are being referred to their fiscal intermediaries for collection of overpayments.
The guidelines, released last year by HHS, and another set issued by the U.S. Justice Department helped derail a hospital industry-backed bill aimed at curtailing the government's use of the False Claims Act in healthcare fraud (June 15, 1998, p. 2).
Providers had criticized the government for extracting settlements from them by threatening enforcement of the False Claims Act, which can impose triple damages.
Also earlier this month, the General Accounting Office issued the first of two reports on the Justice Department's compliance with internal guidelines on use of the False Claims Act.
While the report said it was too early to reach a conclusion, it did surmise that fewer national anti-fraud investigations were opened. The report also said about 50% of the investigations that were closed resulted in no adverse action against providers.