Illinois physicians and healthcare professionals: Are you prepared in the event of an OIG audit or review?

Not only do healthcare providers need to be concerned with federal compliance with government funded benefit programs like Medicare, there are state compliance agencies who oversee and audit physicians and healthcare systems to make sure there are no shortcomings in the state-funded benefit systems. In Illinois, the Office of the Inspector General (“OIG”) operates as a division of the Illinois Department of Healthcare and Family Services. The OIG’s stated mission is, “to prevent, detect and eliminate fraud, waste, abuse, misconduct and mismanagement in programs administered by Healthcare and Family Services and the Department of Human Services.[i]” The OIG focuses its efforts in fraud prevention, investigations, audits and reviews, sanctions and restrictions, and safety and security.

The OIG in Illinois is highly focused on preventing fraud on the Illinois Medicaid Program and it uses advanced technologies and methods to detect and track activities that could be fraudulent. When possible the OIG conducts preventative verifications of the people and systems involved in tracking medical equipment, the prescribing and delivery of medications and healthcare services.

Illinois Medicaid Fraud Investigations

Fraud can stem from many sources including public aid recipients as well as employees and healthcare service contractors. When a report is made that fraudulent activity may be occurring, the OIG is tasked with investigations to determine if a fraud is being perpetrated on the system. The OIG works closely with a variety of state agencies and authorities to investigate and stop fraud. When an investigation produces significant proof of fraudulent conduct the proper agencies may arrest and bring criminal charges against any individuals involved in defrauding the state.

Audits and Reviews in the Illinois Medicaid Program

In addition to investigating suspected fraud cases, the OIG also conducts a variety of audits and reviews of the Illinois Medicaid System:

1. Post-payment compliance audits – are all the payments made to Medicaid providers identified and proper?
2. Quality of care reviews – are proper healthcare services being performed for patients who rely on state funded Medicaid and related programs?
3. Eligibility reviews – are the people receiving Illinois Medicaid eligible within the system requirements?

What to do if you receive notice of an audit or review by the OIG

In the event the OIG notifies you that they are planning an audit or a review of your healthcare practice, policies and procedures in connection with the application or receipt of reimbursements from Illinois Medicaid or any other program under the authority of the OIG, it is important to immediately contact a healthcare attorney to make sure you are properly organized and prepared to cooperate with the audit or review.

While there may be advanced notice or warning of an audit or review, in cases where a fraud report has been filed with the OIG and they have already been investigating the complaint in the background, the audit might be less routine and more of an evidence gathering exercise. The advice to call a lawyer still applies, and moreover, talking to a lawyer before there is any reason to worry about an audit is a good idea. Just as you maintain a malpractice policy and never plan to use it, maintaining a plan of action in the event of an OIG audit is a prudent move for any healthcare provider.

Michael V. Favia is an experienced healthcare attorney who worked for the State of Illinois and knows first-hand how state investigations and prosecutions proceed and how to properly cooperate.

The former Chief of Prosecutions for the Illinois Department of Professional Regulation, now known as the Illinois Department of Financial and Professional Regulations (“IDFPR”), Michael V. Favia advises and represents healthcare professionals and organizations in a variety of matters, including routine, and not-so-routine audits, reviews and investigations. Favia knows the state regulatory schema and system and can help healthcare professionals craft a plan and be prepared in the event the OIG or another agency comes knocking at their office door.

Chicago health law and litigation attorney Michael V. Favia and his associates in several locations and disciplines, advise and represent licensed physicians in all types of litigation and administrative matters involving licensing and regulatory agencies.

Michael V. Favia and Associates, P.C. represents individual physicians and health care organizations in the Chicago area with a variety of legal matters. With offices conveniently located in the Chicago Loop, Northwest side and suburban meeting locations, you can schedule a discrete meeting with an attorney at your convenience and discretion. For more about Michael V. Favia & Associates, please call (773) 631-4850, visit www.favialawfirm.com and feel free to “Like” the firm on Facebook and “Follow” the firm on Twitter. You can also review endorsements and recommendations for Michael V. Favia on his Avvo.com profile and on LinkedIn.

 

[i] IL Dept. of Health and Family Services, Office of the Inspector General, mission.

Opioid Addiction: Issue spotting in workers’ compensation, addressing systemic abuse

When does workers’ compensation lead to addict’s compensation?

Painkillers are a big problem in the workers’ compensation industry. Many Americans are addicted to opioids and there are too many opportunities to fuel the fire of abuse. Workers’ compensation and the healthcare system are significant in causing an increasing amount of opioids in society. From a school librarian with an ankle sprain and a prescription to the street dealers selling oxycodone to high school kids planning to sell them at parties, most people know at least someone with an opioid experience.

While most responsible patients properly manage their recovery, carefully following care instructions, others are not so diligent. In too many cases, the most unlikely people find themselves becoming dependent, then addicted to painkillers. Many people who just need another refill, repeatedly, look like any other healthy friend, neighbor or family member.

When does workers’ compensation lead to addict’s compensation?

Pharmaceutical companies like Purdue Pharma, Phizer and Janssen Pharmaceuticals produce and provide doctors, hospitals and pharmacies with oxycodone (OxyContin), morphine (Avinza) and fentanyl (Duragesic), respectively[i].   

Opioid addiction is an issue many health care administrators spot with increasing frequency. According to Joseph Paduda, principal of Health Strategies Associates, Inc., “There are more than 200,000 workers’ compensation claimants who have been on a high dose of opioids for more than six months. The vast majority of them are addicted.[ii]”

For many, a workers’ compensation claim, hospital visit and opioid prescription is a first-time experience. However, others know exactly what they are getting; get hurt and score. Paduda says, “The data indicates that about 19 percent of claimants who are prescribed opioids, when they’re tested, there’s no evidence of the drug in their urine. That means those opioids prescribed to workers’ comp claimants are getting in the hands of people who are going to use them for illicit purposes.[iii]”

Technology: Advances in healthcare processes make it easier to use the workers’ compensation system on a path to painkillers.

In days past, workers’ compensation claimants drove to their nearest workers’ compensation commission office to talk to staff about procedures, fill out paperwork and file a claim or obtain status information about their case. Today, the process is web-interactive and injured workers can learn all the information they need to file a claim online and update their case.

The data collection and information sharing systems used in the healthcare industry largely fell short in combating systemic abuse. In contrast, “a well-functioning workers’ compensation system allows insurance carries, state insurance funds, and self-insured entities to efficiently manage the core process of underwriting workers’ compensation policies and investigating and processing claims. Historically, these entities have faced a number of challenges in carrying out these functions, particularly in claims.[iv]”

New and improving software platforms and systems sharing information among qualified users can make it easier to spot patterns of abuse and anomalies in patient claims. As the healthcare and workers’ compensation industries adopt new technologies there should be tighter controls on the production, sale and distribution of painkillers; proactive abuse prevention is important to cutting off the supply to those addicted to morphine, oxycodone and all the other opiate drugs.

The Chicago law firm of Michael V. Favia & Associates and its affiliated Illinois Professional Licensing Consultants, work to keep everyone informed about news and resources in healthcare and workers’ compensation.

Michael V. Favia & Associates and the Illinois Professional Licensing Consultants, of whom Michael V. Favia is a primary attorney, are available to work with individuals interested in these matters. With offices conveniently located in the Chicago Loop, Northwest side and suburban meeting locations, an attorney will be able to assist at your convenience and discretion. For more about Michael V. Favia & Associates and their professional licensing work, please visit www.IL-Licensing.com and feel free to “Like” the firm on Facebook and “Follow” the firm on Twitter.

[i] FDA, Drug Safety Information By Drug Class, List of Extended-Release and long-Acting Opiod Products Required to Have an Opioid REMS.

[ii] Insurance Journal, Magazine Features, 10 Challenges Ahead for Workers’ Compensation, by Andrea Wells, May 5, 2014.

[iii] See HNii above

[iv] AASCIF.og, The Impact of Modern Technology on Workers’ Compensation Claims, by Sandy Leyva, Jan-Mar. 2006.