Compliance Frequently Asked Questions
What should I do if I am approached by a government investigator?
If you are contacted by a government investigator while working at a UConn Health workplace or other approved work location, you should first ask the investigator to see identification, including a business card. Next, notify your supervisor, who should immediately notify the UConn Health Office of the General Counsel (OGC) to announce the investigator is on site. If your supervisor is not available, leave a message and contact the OGC directly. For more information please refer to the Protocol for Responding to Government Investigations.
What is the False Claims Act?
The federal False Claims Act prohibits any person from knowingly presenting, or causing to be presented, a false or fraudulent claim for payment to the federal government. Knowing means you have actual knowledge that the information is false, or you are acting in deliberate ignorance or reckless disregard of the truth or falsity of the information.
Connecticut has its own false claims act that applies to fraud against CT Medicaid and other medical assistance programs administered by the Connecticut Department of Social Services.
What is the Anti-Kickback Statute?
The federal Anti-Kickback Statute prohibits the exchange of anything of value for referrals for services that are payable by Medicare, Medicaid, or other federal healthcare programs.
What is Stark Law?
The Physician Self-Referral Law, also called the “Stark Law,” prohibits a physician from referring a Medicare or Medicaid patient to an entity (like a hospital) for certain designated health services (DHS), if the physician (or an immediate family member) has a financial relationship with the entity. The entity is likewise prohibited from billing Medicare and Medicaid for any of those services.
What is the OIG Work Plan?
The Office of Inspector General (OIG) is continuously assessing, evaluating and prioritizing issues that put Health and Human Services programs (HHS) at risk. The Work Plan is a listing of high risk focus areas where the OIG will assign resources to conduct audits, reviews or investigations. The Work Plan is updated monthly and items are added and removed as new risk priorities are identified and reviews are completed.
Since UConn Health participates in several HHS Programs such as the Centers for Medicare and Medicaid Services and the National Institutes of Health, we monitor the Work Plan to evaluate our risk related to items on the Work Plan.
There are so many regulations I have to comply with. How can I keep up with them all?
UConn Health is subject to many state and federal laws and regulations related to healthcare, many of which are aimed at preventing and combatting fraud, waste and abuse in Medicare, Medicaid and similar government programs. Please reach out to the Office of Healthcare Compliance and Privacy with any questions or concerns regarding the regulations and intuitional policies that you are required to comply with.
How often do employees need compliance training?
Per University policy, all faculty and staff are required to complete the annual Healthcare Compliance and HIPAA Privacy training. The Office of Healthcare Compliance and Privacy develops and delivers healthcare compliance and privacy training and education to the UConn Health community. Please refer to the Education and Training FAQ’s for more information.
What are healthcare RAC audits?
Recovery Audit Contractor (RAC) audits seek to identify improper Medicare fee for service payments to health care providers on behalf of the Centers for Medicare and Medicaid (CMS). RACs perform post payment audits which typically involve reviewing the medical record documentation supporting services that were billed to and paid by Medicare. Any overpayments identified by the RACs are recouped from the health care provider.
What is a Medicare Administrative Contractor?
A Medicare Administrative Contractor (MAC) is an agency hired by the Centers for Medicare and Medicaid (CMS) to manage the Medicare program for a geographic region within the United States. Currently, there are seven MACs which process Medicare claims, set coverage policies, enroll providers, establish billing requirements and conduct medical reviews on behalf of CMS. The MAC for UConn Health is National Government Services.
What are Target, Probe and Educate Reviews?
Target, Probe and Educate (TPE) Reviews are authorized by the Centers for Medicare and Medicaid (CMS) and are conducted by the Medicare Administrative Contractors (MACs). The reviews are designed to improve compliance with Medicare’s coverage guidelines and reduce payment denials and appeals. Health care providers subject to a TPE will be asked to submit medical chart documentation for review. Based upon the review findings, providers receive education aimed at improving compliance with Medicare’s coverage guidelines. Any overpayments identified during the review are recouped from the healthcare provider.
What are Comparative Billing Reports?
Comparative Billing Reports (CBRs) compare an individual provider’s billing practices and patterns to their peers both at both the state and national level. CBR’s are authorized by and issued on behalf of the Centers for Medicare and Medicaid (CMS) and are based on billed Medicare claims data. Only providers whose billing patterns are outliers in relation to their peers will receive a CBR. CMS requests that providers receiving a CBR review their billing practices to assure that they are in compliance with Medicare coverage guidelines.
What is EMTALA?
EMTALA is the Emergency Medical Treatment and Labor Act. EMTALA requires the hospital to provide an appropriate medical screening examination to any person who comes to the Emergency Department seeking treatment for an emergency medical condition, including active labor, regardless of the individual’s ability to pay.
What is exclusion checking?
Exclusion checking is UConn Health’s process of verifying that a current or potential employee, contractor, vendor, student, resident, fellow or volunteer is not classified as excluded, suspended or debarred by any Federal agency and certain state agencies. Please refer to the exclusions checking FAQs page for more information.