Editor’s note: This article was submitted by the Texas Office of Inspector General as part of a campaign to help educate physicians and other health care professionals on how to identify and avoid common billing mistakes. Physicians should consult with their own retained counsel when determining whether to report a potential overpayment.
More physicians are taking advantage of the opportunity to self-audit and self-disclose overpayments during the course of a Texas Health and Human Services (HHS) Office of Inspector General (OIG) investigation. Self-reports to the OIG in fiscal year 2021 lead to the resolution of 45 cases, totaling $8.1 million; only 12 self-reports were made just three years earlier. Those using the self-report process include physicians, clinics, hospitals, home health agencies, and mental health rehabilitative services entities.
The OIG developed a protocol to offer guidance to physicians and other health care professionals who decide to voluntarily disclose irregularities in their dealings with Medicaid and other state health and human service programs. Working together with physicians through this self-disclosure approach enhances the OIG's overall efforts to eliminate fraud, waste, and abuse, while offering physicians an opportunity to reduce their legal and financial exposure. Proactively collaborating with the OIG may also lead to more thorough understanding of the OIG's audit and investigatory processes.
The OIG may consider self-reporting as a potential mitigating factor that may warrant less severe or restrictive administrative action or sanction.
The process
Physicians who identify that they have received inappropriate payments from the Medicaid program are obligated to report and return the overpayments within 60 days. However, the OIG understands the need for a fair, reasonable process for the State of Texas and the physician involved.
The protocol for self-reports begins with notifying the OIG on self-assessed issues, such as billing errors, services not rendered, or hiring excluded individuals. The physician must provide documentation or data to support the issue and amount of overpayment received (paid claims). The OIG reviews policy, documentation, and data to confirm the violation and amounts associated. However, sometimes a report arises out of caution, and there is no overpayment associated.
Self-disclosing overpayments can allow a physician to potentially avoid prolonged investigation and litigation and the costs associated with each.
The benefits
The OIG is neither bound by any findings submitted by the self-disclosing physician nor obligated to resolve the matter in any particular manner, but findings made through the self-disclosure process are weighed in determining any enforcement measures and can mitigate possible penalties or sanctions.
While an investigation by the OIG’s Provider Investigations unit can lead to administrative enforcement measures, including recovery of overpayments, the OIG’s Chief Counsel division works with physicians who elect to cooperate with an investigation by self-disclosing overpaid amounts, whether resulting from simple error or intentional fraud.
The OIG may conclude that the disclosure warrants a referral to other county, state, or federal authorities for additional civil or criminal enforcement. If the OIG makes a referral, it will include the physician's involvement and level of cooperation throughout the disclosure process.
The specific resolution of self-disclosures depends upon the individual merits of each case, but the OIG may extend the following benefits to physicians who initiate a good-faith self-disclosure:
- Forgiveness or reduction of interest payments (for up to two years);
- Extended repayment terms;
- Waiver of penalties or sanctions;
- Timely resolution of the overpayment; or
- Recognition of the effectiveness of the provider's compliance program and a decrease in the likelihood of imposition of an OIG Corporate Integrity Agreement.
To report
Physicians may use the OIG Fraud Hotline (800-436-6184) or website, ReportTexasFraud.com, at any time to report any compliance or overpayment matters relating to themselves. Additional information about the self-disclosure process and a checklist of information to include can be found in the Resources section of the OIG website.
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