OIG Issues Hospital Compliance Guidelines

The OIG released its official hospital compliance guidelines on February 11, 1998. The model compliance guidelines, issued only a short time after the leak of an earlier version, address fundamental principals of hospital compliance programs and set out a number of specific elements to be included in such compliance plans.

According to the OIG guidelines, hospital policies and educational programs should pay particular attention to issues identified by the OIG as being of special concern, including:

• Billing for items or services not actually rendered
• Providing medically unnecessary services
• Upcoding
• DRG creep
• Outpatient services rendered in connection with inpatient stays
• Teaching physicians and resident requirements
• Duplicate billing
• False cost reports
• Unbundling
• Billing for discharge in lieu of transfer
• Patients' freedom of choice
• Credit balances–failure to refund
• Hospital incentives that violate anti-kick back laws
• Joint ventures with physicians
• Financial arrangements with hospital-based physicians
• Physician self-referrals under the Stark law
• Withholding services from HMO members
• Patient dumping.

The official guidelines differ from the earlier leaked version with respect to reporting suspected misconduct. The new guidelines require such reports not more than 60 days after determining there is credible evidence of a violation. The earlier version would have required such reports to be made within 30 days of learning of an alleged violation, whether or not it had been determined that the alleged violation was supported by fact.