It’s Time to Review Your Compliance, Data and Auditing Plans

As we near the end of 2018, healthcare providers and companies are understandably focused on 2019 and the trends ahead. In planning for next year, however, healthcare companies throughout Tennessee ought to pay heed to a new development at the end of this year — the announcement of a new federal healthcare-specific strike force centered in Nashville and the surrounding region.

New Strike Force Based in Nashville, Nearby Districts

In October, the Department of Justice (DOJ) announced that Nashville will be the hub for the Appalachian Regional Prescription Opioid (ARPO) Strike Force. The newly formed strike force is a joint effort of nine United States Attorney Offices – the Eastern, Middle, and Western Districts of Tennessee; the Eastern and Western Districts of Kentucky; the Southern and Northern Districts of West Virginia; the Southern District of Ohio; and the Northern District of Alabama – along with the Health Care Fraud Unit of DOJ’s Criminal Fraud Section; the Federal Bureau of Investigation (FBI); U.S. Health and Human Services Office of the Inspector General (HHS-OIG); U.S. Drug Enforcement Agency (DEA); U.S. Postal Inspection Service; IRS Criminal Investigation; and State Medicaid Fraud Control Units. 

The ARPO Strike Force is based on the Medicare strike forces that operate in 12 locations across the country. DOJ’s Strike Force model is designed to be a force multiplier, combining the resources and expertise of DOJ’s Fraud Section, United States Attorney Offices, and law enforcement agents and analysts. Since the inception of the strike forces in 2007, over 4,000 individuals have been charged with fraud and related offenses. In June 2018, a national healthcare fraud enforcement action resulted in charges against 601 individuals across 58 federal districts. 

Focus on Opioids, But Likely Broader

The new strike force is generally focused on prescription drugs and opioid-related crimes. According to the DOJ press release, “[t]he ARPO Strike Force will target criminal conduct associated with the improper prescription and distribution of prescription opioids and other dangerous narcotics throughout the Appalachian region and surrounding areas – focusing on criminal conduct by physicians, pharmacists, and other medical professionals.” 

While the primary focus of the ARPO Strike Force will be rooting out opioid-related crime, a much broader focus on healthcare fraud and enforcement generally will follow. Also from the press release: “[t]he ARPO Strike Force will also investigate and prosecute violations of health care fraud whenever such fraud is detected throughout the region.” Indeed, similar coordinated efforts in the past have often reached far beyond the narrow original mandate, and we expect this strike force to be no different.

Takeaways for Healthcare Companies and Providers

With Nashville serving as home base for the ARPO Strike Force, there will be an increased focus on healthcare providers in and around the metro area. It is worth noting that since the announcement of the ARPO Strike Force on October 25, the Middle District of Tennessee has announced a civil False Claims Act suit involving pain management clinics in Tennessee, North Carolina, and Virginia, as well as a criminal indictment charging a Tennessee dentist and former practice administrator with healthcare fraud conspiracy. 

Healthcare providers and companies should plan ahead. With increased funding comes increased scrutiny, and companies should expect the enforcement environment to become even more stringent. Here are some practical, proactive steps healthcare companies should consider as part of their year-end review and to mitigate the risk of government scrutiny in the year ahead:

• Compliance plan update. Review compliance plans and implement any necessary updates based on policy or statutory changes.
• Training review. Update and document your training on coding and billing issues.
• Reporting functions. Review your reporting avenues for efficiency and ease of use, including web-based systems, employee hotlines, or other outlets for employees to raise concerns.
• Auditing process. Reconsider your billing and chart auditing process to ensure it is current and done under the direction of counsel to protect it from disclosure.
• Data management. Review your broader data-retention and archival policies and update them with the help of counsel and technical consultants (one of the biggest drivers of risk and cost is excessive amounts of stored data that can become subject to disclosure in litigation or investigations).

While no steps can completely protect against government scrutiny, providers can reduce their risk exposure through these general steps and additional compliance planning tailored for their specific company.