OIG Guidance

Transcript

Hi, my name is Amanda Walker. I'm an attorney with the office of the Inspector General.

Many people ask: Where do I look for OIG guidance on compliance programs and the fraud and abuse laws?

What resources will best help my organization? How do I get started without feeling overwhelmed?

Well, we understand, and that's why I'm going to walk you through our published guidance, explain how the different materials work, and highlight key areas to get you started.

There are three main categories.

Our most comprehensive collections of information, organized by industry sector, are the Compliance Program Guidances, better known as the CPGs. Next there's more specific information highlighting particular areas of fraud and abuse. These are the Special Fraud Alerts, Special Advisory Bulletins, and Other Guidance. And finally we'll look at advisory opinions and explain how they can be used.

All of these materials are posted on our web site, www.oig.hhs.gov. Just click on the Compliance Tab on our home page.

Let's begin with OIG's Compliance Program Guidance, which we call CPGs for short. They not only provide information on building an effective compliance program—they also give overviews of the fraud and abuse laws you need to know about and give examples of risk areas to avoid violating these laws.

CPGs are organized by industry sector. You'll see that we've issued 11 originals and 2 supplementals to date—aimed at particular providers and suppliers—such as hospitals, nursing facilities, physician practices, third party medical billing companies, just to name a few.

Some CPGs are older than others, but it's all still good guidance to consider. And while these documents are written in the context of a particular industry, it's helpful to review those written for sectors other than just your own. The principles and risk areas we lay out in these documents can be useful in contexts across the industry.

For example, let's say you are a physical therapy group looking to enter into an arrangement with a nursing home... there isn't a CPG for physical therapists but there is a CPG and supplemental for nursing homes. The physical therapy group would benefit from reviewing the proposed arrangement in light of the risk areas laid out in the nursing home CPGs. This could help identify potential red flags for parties on both sides of the arrangement.

When we talk about compliance programs in the CPGs, we do so in terms of principles and suggested practices. We do not provide a model compliance program because we recognize that every organization is different, and the CPGs are not intended to be one size fits all guidance. Ask yourself the questions we set forth about your own organization or arrangement. Tailor the principles to your own circumstances. Focus compliance efforts on potential risk areas most relevant to your organization. Remember, the risk areas are those instances when you need to proceed with caution because the arrangement may violate the fraud and abuse laws.

Next let's move on to special fraud alerts, special advisory bulletins, and that large category named "other guidance." You can also find these materials on the compliance tab on OIG's home page.

When does OIG issue this type of guidance? When certain trends of fraud and abuse are identified and the industry and public need to know. For example: there's a Special Advisory Bulletin on Contractual Joint Ventures and the Fraud Alert on Waivers of Beneficiary Co-payments.

Again, some of these documents might be older than others, but it's still all guidance we refer people to everyday.

It's important to become familiar with these materials, as there might be a piece of guidance directly on point that answers a question you have about your business.

Let's finally look at advisory opinions. This is a special process that allows parties to seek formal and binding legal guidance from the OIG about specific business arrangements.

Advisory opinions offer legal protection from prosecution for the party who made the request, and only to that party—no one else.

So why do we publish our advisory opinions? They can serve as excellent guidance, as we employ consistent analysis to consistent facts.

Let's say you're considering a business arrangement, and you've reviewed our published advisory opinions and other guidance materials, and you decide it's best to submit your own request. The process for requesting an advisory opinion is laid out in the form of frequently asked questions. Please be certain to review the Frequently Asked Questions page on our web site before submitting a request to ensure you have met all of the requirements for acceptance of your submission. And the more complete your request is, the faster your request can be processed.

We do not issue opinions on hypotheticals. But as long as you are a party to an arrangement or in good faith plan to enter into one, you can write in to the OIG with a full description of the facts. We will analyze whether it runs afoul of the anti-kickback statute OR other laws enforced by this office.

A practical tip for all of our guidance materials: Use the advanced search feature on our web site. You can pull everything we've published on a given topic using this tool. It's very comprehensive. I use it all the time myself.

Here's what's important. Keep your organization up-to-date. Sign up on our web site for OIG's email list to receive the latest guidance as it's issued. You can also follow us on twitter. OIG wants to make sure you have the resources and tools you need to comply with the Federal fraud and abuse laws and share in our mission to protect the integrity of our Federal health care programs.