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A Tool for Practical Compliance: The HCCA – OIG Compliance Resource Guide

April 18, 2017

Data quality is the most important element of a compliance practice. FACIS ® is the gold standard of health care data.

The result of a Compliance Effectiveness Roundtable held January 17, 2017 in Washington DC is the, “Measuring Compliance Program Effectiveness – A Resource Guide” (https://oig.hhs.gov/compliance/101/files/HCCA-OIG-Resource-Guide.pdf).

Participants of the round table included compliance professionals and staff from the Department of Health and Human Services, Office of Inspector General (OIG).

The Resource Guide, released March 27, 2017, describes seven core elements of a compliance program and suggests ideas about what and how to measure the effectiveness of compliance programs. The hundreds of options take into consideration a broad range of organizations and respective sizes, shapes, styles, practice types, and resources.

The suggestions are abundant but can be confusing when arranging in order of natural sequence and priority. As legacy experts in the screening, monitoring and health care compliance space, Verisys can help compliance officers establish and maintain a best-practices organization in line with the effectiveness measurement suggestions.

The third core element of the resource guide is centered on: “Screening and Evaluation of Employees, Physicians, Vendors and other Agents.” Subcategory items include the verification of background/sanction checks and monitoring. The suggestions supplied by the OIG regarding element three are confusing and create concerns around inherent risk of what is required of a compliance program.

In most cases, the various departments engaged in screening will use different databases or screening services with vastly disparate levels of accuracy and quality. The human resources department may use a third-party screening service, the credentialing department may be required to work through a state CVO and the compliance department may rely on the OIG search service plus the National Practitioner Data Bank (NPDB).

There are no guidelines suggesting the use of the highest quality data and solid verification standards. Verisys’ proprietary database, FACIS® (Fraud Abuse Control Information System) dates back to 1988 and has more than 176 million records informed by actively tapping 5,100 active and inactive sources and continuously exclusion monitoring over 5 million providers.

This is compared to the OIG searchable database that at any given time dates back five years and relies on reporting for its content. The use of NPDB is mandated, yet it contains a fraction of the amount of records contained in FACIS. Without using FACIS ®, the screening and verification process is checking against data that leaves huge gaps inviting exposure for waste, fraud and abuse, patient endangerment, as well as legal issues with corrective, remedial and dismissal processes and procedures.

“Scamming the health care system is endemic and drives up the cost of health care, eliminating fraud would be a giant step toward achieving Congress’ goal of affordability,” says John Benson, Verisys CEO. “It would require massive changes to existing flawed systems and challenging the CMS contractors whose very expensive systems just add more cost by engaging in the pay and chase game. We need to have an honest discussion about prevention and it starts with a solid gatekeeping and monitoring strategy, something that Verisys delivers in the commercial sector today. The government needs to stop spending money on magic bullets and start applying common sense solutions.”