Preparation and Response to DCH Open Letter Michele Madison,Esq. Holly Pierson, Esq.

ENFORCEMENT ACTIVITIES The RACS are Coming... The MACS are Coming... DCH –OIG is here

Welcoming the Government Multiple forms of Introduction Subpoena Search Warrant On-Site Visit Letter DCH Open Letter 3 Day Readmission Rule Perform Internal Review (Attorney-Client Privilege)

Effective Use of Audits Audits = Preventative Medicine Internal Audits Reimbursement; billing; coding; FLSA OIG Work Plan External Audits Attorney-Client Privilege Remedial Action and Re-evaluate

Attorney-Client Privilege Utilize the Attorney-Client Privilege Direction by Attorney Review Audit Results Legal Advice Regarding Audit

GA SELF-DISCLOSURE PROCESS Georgia Self-Disclosure Protocol -- Part I, Policies an Procedures Manual for Medicaid, Section

GA SELF-DISCLOSURE PROCESS Providers are encouraged to self-audit to identify claims errors and overpayments Once errors or overpayments identified, “providers must alert the Department and work toward a resolution or refund.”

GA SELF-DISCLOSURE PROCESS Self-Disclosure Letter to PIU at OIG must include the following: 1.A full description of the matter, the person who identified the overpayment and the manner in which it was discovered; 2.Detailed account of the investigation of the overpayment; 3.Whether the provider is under investigation by a government agency; 4.The provider’s theory regarding the cause of the violation; 5.The methodology used to determine the amount of the overpayment; and 6.Certification that the disclosure is a good faith effort to disclose a billing inaccuracy and is true and correct under penalty of perjury;

GA SELF-DISCLOSURE PROCESS Other Key Points Regarding GA Self-Disclosure Protocol: 1.Letter must be accompanied by a Corrective Action Plan (CAP), which details actions taken to correct the cause of the overpayment and steps to prevent future erroneous claims. 2.Self disclosed matters are not subject to appeal rights. 3.Matters uncovered by OIG during the verification process which are outside the scope of the self disclosure may be treated as new matters subject to further investigation. 4.An audit of the provider within 12 months is a mandatory provision of the settlement agreement with OIG. 5.Self disclosure does not absolve the provider of criminal culpability.

Instill INTEGRITY throughout the Organization And be PROACTIVE

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