What Medicaid Providers Need to Know about CIA’s and How They Can Affect Your Practice

I don’t know the backstory regarding MB2 Dental’s Corporate Integrity Agreement (CIA). Here is what I do know:
·      Corporate Integrity Agreements have become a favorite tool of the OIG.
·      You can gain valuable insights on how to protect your practice by reading CIAs (and other government enforcement actions). Every CIA includes requirements that the organization incorporate the OIG’s seven core elements for compliance programs. The core elements were published as voluntary measures in the late 1990’s and early 2000’s. These same measures are mandatory for providers who bill to or receive money from Medicare, Medicaid, and C.H.I.P. yet few organizations even know about these compliance guidances.
·      The OIGs Core Elements of Compliance Programs include: 1). Conducting internal monitoring and auditing through the performance of periodic audits. 2). Implementing compliance and practice standards through the development of written standards and procedures. 3). Designating a compliance officer or compliance contacts to monitor compliance efforts and enforce practice standards. 4). Conducting appropriate training and education on practice standards and procedures. 5). Responding appropriately to detected violations through the investigation of allegations and the disclosure of incidents to appropriate Government entities. 6). Developing open lines of communication to keep practice employees updated regarding compliance activities. 7). Enforcing disciplinary standards through well-publicized guidelines.
·      There are few CIAs involving dental organizations (one involves a dental school). I have reviewed each of the dental related CIAs on the OIG’s website. None indicated that the organization had a corporate compliance program in place prior to entering into a CIA.
·      It was noted on the CIA that MB2 Dental voluntarily established a Compliance Program that provides for a Compliance Officer, a compliance committee, maintenance of various policies and procedures, and auditing and monitoring activities aimed at ensuring their participation in the Federal health care programs conforms to all Federal and State laws and Federal health care program requirements. The CIA ordered MB2 to continue their compliance program. I have never seen where a dental organization had a compliance program in place prior to entering into a CIA.
·      Chapter 8 of the Federal Sentencing Guidelines specify due consideration for organizations found guilty of fraud related offenses. That consideration can reduce fines and penalties by up to 80%. Think about that for a moment. What if the government claimed you made $1,000,000 in errors and, because of your compliance efforts, you only have to pay back $200,000? Would you look back on your efforts and call them a success? Sure you would! This is where compliance efforts can really pay off.
·      I know of numerous dental providers who have run into fraud allegations because a government or insurance auditor did not like their clinical notes, found errors in their billing and even inadequate documentation to support ‘medical necessity’. In every case they were good people paying for mistakes from 3-5 years ago. This means you can put corrective actions in place today to minimize errors in your documentation and billing and STILL face fines and penalties for fraud. In the last year good dentists (just like you) have been put on payment holds, probation, and were kicked out of participation with Medicaid because of auditor’s opinions.
·      Compliance has to be a starting point for everything you do, not an after thought. If you don’t know what you’re doing get help. If you cannot afford help you have a greater problem because you cannot afford not comply with government regulations – getting caught is getting REALLY expensive. The government expects providers to invest a substantial amount of capital toward compliance efforts. The amount Uncle Sam expects you to spend is commensurate with the size of your organization. There is no magic number or dollar amount, but it is not zero.
·      I don’t disclose who my clients are without permission. With their permission I can tell you I consulted for MB2 in 2012. They asked me to help them identify compliance risks and teach them about building their healthcare compliance program. They were committed to building an effective compliance program during my work with them.
·      I recently spoke with representatives of MB2 Dental. We wholeheartedly agree on the importance of dental practices constantly remaining on the cutting-edge of compliance. We hope you will consider their experience and apply what you can learn from it to your practice/ organization.