We found an article recently published on the OIG website that we thought should be republished here.
Providers encouraged to self-report errors
More providers are participating in the OIG self-audit process so they can determine if they need to self-disclose overpayments received from participation in Texas Health and Human Services (HHS) programs. Self-reports to the OIG in fiscal year 2021 lead to the resolution of 45 cases, totaling $8.1 million. Three years earlier only 12 providers self-reported overpayment. The self-report process is available to physicians, clinics, hospitals, home health agencies, dentists, pharmacies and mental health rehabilitative services.
The OIG developed guidance for health care providers choosing to voluntarily disclose irregularities related to Medicaid claims and other HHS programs. The OIG views the program as a way to develop partnerships with providers, allowing the state to reduce fraud, waste and abuse while offering an opportunity for providers to reduce their legal and financial exposure. Working with the OIG may also lead to a better understanding of the OIG's audit and investigatory processes.
Providers who identify that they have received inappropriate payments from the Medicaid program are obligated to return the overpayments; however, the OIG understands the need for a fair, reasonable process for the State of Texas and the provider 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 provider 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 potentially avoid prolonged investigation and litigation, and the costs associated with each.
The OIG is neither bound by any findings submitted by the disclosing provider 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.
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 providers 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 a 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 provider'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 providers 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;
- Recognition of the effectiveness of the provider's compliance program and a decrease in the likelihood of imposition of an OIG Corporate Integrity Agreement.
Providers and managed care organizations may use the OIG Fraud Hotline (800-436-6184) or website, ReportTexasFraud.com, at any time to report 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.