Andrea Treese Berlin, OIG senior counsel, is interviewed by Sheila Davis, a public affairs specialist in Washington DC.
A Native American tribe entered into a settlement with the U.S. government to resolve allegations that the tribe submitted false claims to Medicaid for youth counseling services. I'm Sheila Davis, and this is the HHS OIG's podcast.
The Confederated Tribes of the Colville Reservation is a federally recognized, sovereign Indian tribe with offices in the state of Washington. OIG, along with Federal and State law enforcement partners, investigated the Tribes' billing irregularities from January through August of 2010. OIG Attorney Andrea Treese Berlin worked on this case. Hi Andrea.
[Andrea Treese-Berlin] Hi Sheila.
[Sheila Davis] What were the allegations against the Confederated Tribes of the Colville Reservation?
[Andrea Treese Berlin] It was alleged that Colville submitted false claims to Medicaid for children's mental health services. More specifically, it was alleged that they submitted claims for services provided by an individual contracted provider, and that those claims were submitted for individual, that's one on one, face-to-face services, when what was actually provided were group therapy services.
There's an additional allegation that the services that were provided had little to no clinical value, didn't really address the children's diagnoses, and were not really clinically directed.
[Sheila Davis] And is there anything unique or significant about this specific settlement?
[Andrea Treese Berlin] There are really two unique factors in this case. The first one is the fact that we negotiated the first ever Voluntary Tribal Compliance Agreement. The second thing is the way the claims are paid.
[Sheila Davis] What is the Voluntary Tribal Compliance Agreement - and how will it help?
[Andrea Treese Berlin] The Voluntary Tribal Compliance Agreement is a little different from our standard integrity agreements, because it recognizes that we're really negotiating on a government to government basis, and working with the tribe to try to help cooperatively implement a program that promotes compliance. But the basic elements of the compliance program are required.
For example, Colville had to retain a compliance officer, they had to establish a compliance committee, they've got to establish relevant policies and procedures, they've got to provide pertinent training to their employees, they've got to screen upon hiring and then regularly thereafter to make sure they are not hiring ineligible people. For example, people who have been excluded under the inspector general's exclusion authorities. They've also got to hire an Independent Review Organization, that would be an objective company that would come in and do an annual claims review, and they'll have to undergo an annual review and then they'll also file annual reports with our office.
And, you know, those reports will be viewed by a compliance monitor who is an attorney here at the Office of Inspector General, and that attorney will work cooperatively with the tribe.
[Sheila Davis] If they have questions during this process, can they come to the OIG and ask for guidance?
[Andrea Treese Berlin] Absolutely, that's one of the main functions of the compliance monitors: to work cooperatively, to answer any questions that may come up.
[Sheila Davis] You talked about a couple of unique things with this settlement, and one of them was how claims are paid. So what is unique about how Colville is paid through this settlement?
[Andrea Treese Berlin] These claims are paid under a special law, which has two requirements. The first rule that applies to all Medicare and Medicaid billers, is to follow the rules. All payment requirements need to be met for the claim to be paid by the program. That's really straight forward and that was the conduct that was at issue with this case. It was alleged that they filed claims for individualized services, when they actually provided group services, and you can see why that wouldn't meet the coverage requirements.
This law also requires that all proceeds from billings, that is the profits that would be generated from these billings, need to be reinvested in healthcare services or facilities to be provided to the tribal members.
You can find a lot of additional detail on our website in regard to this issue, and for details go to the Tribal Alert we that issued on November 24th of 2014.
[Sheila Davis] What is the message that the OIG is hoping to send with this settlement and Voluntary Tribal Compliance Agreement?
[Andrea Treese Berlin] The Office of Inspector General is concerned about making sure that Tribal members and program beneficiaries receive the services they need. And part and parcel of making sure that they receive the services they need, is making sure the money is available to pay for those services, and that includes preventing occurrences which drain the scarce resources that Medicare and Medicaid have, because it can jeopardize the program's ability to provide the necessary medical care.
The Voluntary Tribal Compliance Agreement is actually designed as a step to work cooperatively with Colville and help protect tribal children and tribal members by working together to preserve funding for the programs on which they rely. And to try and efficiently promote compliance with the applicable laws and regulations.
[Sheila Davis] Andrea Treese Berlin, Thank you so much for your time. You can read more about OIG's corporate integrity agreements by going to our website. I'm Sheila Davis, thanks for listening.