By Mary Alice Murphy

{Editor's Note: This is part 2 of a series of articles on the Dec. 20, 2023 GRMC Board of Trustees meeting.]

After approving the consent agenda on Dec. 20, 2023, the board members heard updates and reports from Gila Regional Medical Center administrators.

The first was a report and education for the board from Risk and Compliance Director Denice Baird.

She said there are several health care laws. Violations can carry different penalties for civil or criminal cases. The penalties can range from small to very large fines as well as prison time and potential exclusion from providing services.

Baird mentioned the STARK law, which was originally passed to protect patients from fraud or abuse, as well as physician conflict of interest when they refer a patient to a service. Most relate to those patients with Medicare or Medicaid, but can also involve private insurance.

She gave many examples along the way of her explanations.

She said the false claim act deals with how the hospital handles its coding and billing for services rendered. "The violation is in knowing or that someone should have known, but chose to deliberately ignore or disregard the accuracy of the claim. A violation can come with fines, but also potentially triple damages for what the government believes it was defrauded of."

These violations can include billing for a higher amount than the service that was provided or billing for a service not provided, she said, as well as billing for a procedure that was not properly documented. A violation can also include the lack of necessity for a service, such as an MRI or CAT Scan, especially without approval of the insurance company.

Baird gave an example of a recent $29 million settlement for the inaccurate tand overbilling for home oxygen services provided to Medicare patients without proper oversight by certified individuals.

The anti-kickback law is a criminal statute. It is the prohibition of receiving or offering something of value for referrals. "This is an intent statute, so there does not have to be harm to prove to the government that it happened." She noted there are safe harbors but to receive that it must meet every requirement within that harbor. The criminal fines can include imprisonment and exclusion from participation in the federal health programs.

Tied into the anti-kickback law is the beneficiary inducement statute, which prohibits transferring of remuneration for referrals. "They create unfair competition and may rob the patient of safe, quality care."

STARK prohibits a referral to a physician that the referring physician has a financial ownership or relationship with. Again there are safe harbors to protect the good faith relationship that do not promote abuse. She said no intent needs to be proven. It can also hit a false claim violation, as well, Baird said.

The exclusion statute is where the OIG (Office of the Inspector General) can exclude any individual that has violated any of the health care laws or for mistreatment or abuse of a patient. "Once excluded or sanctioned, you cannot bill for services nor can you receive reimbursement. Anyone who hires an excluded person risks having to pay back all the payments the person received before exclusion."

"Because of the financial risk associated with this, the OIG recommends a regular screening process in place," Baird said.

The civil monetary law is where they set the fines and penalties. She said they can range from $10,000 to $50,000 per violation, which can add up pretty quickly. It is in conjunction with the Department of Justice sentencing guidelines, "which determines the culpability. They also take into consideration the strength of your compliance program and its effectiveness."

Baird said the goal of the compliance program is prevention as much as possible, as well as the early detection and correction as early as a potential misconduct is found.

"We work to prevent those violations through our code of conduct and internal and external assessments," she said. "We also do regular reporting on compliance and risk to the board. All of our staff are encouraged to report any concerns they have. We have signs that say: 'If you see something, say something.' They can report through the compliance hotline anonymously or they can call me or email me about an issue."

Board vice chair Betty Vega asked if the risk and compliance department has audits and internal controls.

"We have some, as we continue to do our risk assessments, which should be done this month, and we will determine what things are of higher risk, and we can add additional reports," Baird said. "The financial team has an integrity person who goes through all the billing."

Board Member Seth Traeger said it was great to have a robust compliance and risk system in place. "It sounds like the assessment piece will determine what needs to be added."

Board Secretary Pat McIntire asked if it was the time to dig into the compliance program.

Baird said if there were more questions they should be addressed in executive session.

The next report will come from Chief Nursing Officer Ron Green.

To read the previous article, please visit: https://www.grantcountybeat.com/news/news-articles/82205-grmc-held-board-of-trustees-meeting-122023-part-1