Are Managed Care Companies Really as Sinister as We Think They Are?

As a healthcare provider who has experienced the growth of managed care over the years, I have shared the same perception as other providers: managed care companies are operated by people who sit around in conference rooms scheming on how not to pay providers for care they deserve to be paid for. As providers, we tend to demonize managed care executives. We ascribe to them purposeful, planned strategies to avoid paying what they should be paying, and we tend to blame them when we don’t receive the reimbursement we deserve. A few years ago, I had the opportunity to provide consulting services to a managed care company that was preparing to launch a new product. When I went to their offices, with the preconceived notions I described above, and looked for the conference rooms full of scheming executives, I was disappointed. What I found instead were hardworking people—even nice people—who had a job to do, and a pretty complicated one at that. They needed to manage the payment for services, with a limited amount of premium dollars, in the backdrop of a highly regulated industry. As it turns out, they were not much different than the providers! They wanted to get it right, and often could not understand why providers didn’t bill it right. To prove I have not totally gone over to the dark side, I will point out some other observations: while providers are client–facing, with a sense of urgency to deliver care, this same urgency was missing in the halls of comfortable offices—where the client is miles away. We would spend not just hours, but days...

U.S. TIGTA Urges Taxpayers to Remain on “High Alert”

WASHINGTON — The Treasury Inspector General for Tax Administration (TIGTA) urged taxpayers to remain on “High Alert” and announced additional outreach efforts to prevent them from falling victim to criminals who impersonate Internal Revenue Service and Treasury employees this filing season. “The phone fraud scam has become an epidemic, robbing taxpayers of millions of dollars of their money,” said J. Russell George, the Treasury Inspector General for Tax Administration. “We are making progress in our investigation of this scam, resulting in the successful prosecution of some individuals associated with it over the past year,” he said, adding that over the summer, a ringleader was sentenced to more than 14 years in federal prison.  “However, this is still a matter of high investigative priority.” TIGTA continues to receive reports of thousands of contacts every month in which individuals fraudulently claiming to be IRS officials make unsolicited calls and “robocalls” to taxpayers and demanding that they send them cash, he said. “As the tax filing season begins, it is critical that all taxpayers continue to be wary of unsolicited telephone calls and e-mails from individuals claiming to be IRS and Treasury employees,” said the Inspector General. “This scam has proven to be the largest of its kind that we have ever seen. The callers are aggressive and relentless,” he said. “Once they have your attention, they will say anything to con you out of your hard-earned cash,” George added. “We will be very aggressive in pursuing those perpetrating this fraud,” the Inspector General said. “In the meantime, we need to do even more to warn taxpayers not to fall for it,”...

2016—The Year a Compliance Review/Audit May Arrive at Your Door!

Another year has come and gone and the experience level and recoupment efforts of the OIG and OMIG get better and better.  The roles of today’s Corporate Compliance Officer are varied and many Corporate Compliance Officers are not familiar with designing and/or implementing internal controls or developing policies and procedures that assure compliance with numerous laws. Before year-end, the NYS OMIG conducted numerous webinars that highlighted the elements of an effective compliance program and who is required to file the two certifications—the DRA and SSL. Once you have certified to the OMIG that you have an effective compliance program and have updated the OMIG’s assessment tool, here are items you need to consider prior to a review from the Bureau of Compliance (BOC):   Support for all eight requirements (written policies and procedures, designation of employee with compliance responsibilities, training and education, communication lines to the responsible compliance position, disciplinary policies to encourage good faith participation, system for routine identification of compliance risk areas, a system for responding to compliance issues, and a policy of non-intimidation and non-retaliation.) An organization chart that indicates the Compliance Officer and the reporting line A New 2016 compliance work plan that is prepared and approved by the Board. An annual risk assessment identifying organizational weaknesses which need to be addressed. The BOC letter of invitation requests information that substantiates your claim to having an effective compliance program. Therefore, you will need to provide: minutes of the Compliance Committee meetings proof of training of board, management, staff, and all affected individuals proof of the reviews performed documented specific policies that correlate to the eight requirements...

U.S. Labor Department Said More U.S. Companies Classify As “Joint Employers”

According to an article written by Robert Iafolla, Andrew Hay, and Alexia Garamfalvi; and published by Reuters on Thursday, January 21, 2016: More U.S. companies could be classified as “joint employers” of workers employed by a staffing agency or contractor and held liable for labor violations tied to those staff, the U.S. Labor Department said in guidance published Wednesday. Joint employment has emerged as a major issue in franchising, contracting, temporary staffing and other arrangements in which companies use workers but do not directly employ them. The guidance could affect companies ranging from construction firms to restaurant chains that might be held responsible if, for instance, one of their temp workers did not get paid minimum wage by her employer. “As the workplace continues to fissure, and as employment relationships continue to become more tenuous and murky, we will continue to identify where joint employment applies and to hold all employers responsible,” David Weil, the administrator of the Labor Department’s Wage and Hour Division, said in a blog post Wednesday. The department is tasked with enforcing the Fair Labor Standards Act, which sets out standards for minimum wage and overtime pay. The guidance can be used in litigation and administrative proceedings and courts may pay deference to it, though they are not required to because it is not a formal regulation. In a 15-page document the department explained how to analyze joint employment in “vertical” arrangements, when one company contracts with another company, and “horizontal” arrangements, when one worker is employed by two related companies. The guidance comes as the Obama administration is moving to make millions more Americans...