Recent Corporate Integrity Agreements (CIAs) between physician practices and the U.S. Department of Health and Human Services Office of Inspector General (OIG) are showing a new trend of requiring an increasing number of certifications by both the practice and its Independent Review Organization (IRO). In fact, the terms “certification” and “certify” are used multiple times in such CIAs, stressing their growing importance. These certifications must be taken seriously, as the CIA provides for a stipulated penalty of $50,000 for each false certification submitted by or on behalf of a physician practice as part of its Implementation Report, Annual Report additional documentation requested by OIG or as related to other requirements under the CIA.
Managing Senior Consultant at Strategic Management, Thomas Herrmann, JD, formally served in the Office of Counsel to the OIG for over twenty years. During his tenure he specialized in providing IRO services for physician practices. He explains that the OIG has learned over time how to best address adherence to CIA requirements by physician practices through certifications. Inasmuch as physician practices tend to be smaller than other types of health care entities entering into CIAs, and often involve one or only a few principles, the OIG requires that key individuals provide certifications of compliance. The OIG also requires that there be a certification of compliance with all requirements of the CIA. There is also a focus on the independence and expertise of the IRO engaged to review claims or arrangements, as well as ensuring that there is no interest in a third party billing company with whom a practice contracts. A critical requirement is the certification of having reviewed both the Implementation Report and Annual Report, having made a reasonable inquiry regarding content, and having the belief that the information contained therein is accurate and truthful.
The following are examples of certifications that a physician practice must make and include in its Implementation and Annual Reports to the OIG:
- The practice has maintained written documentation that all Covered Persons have received compliance training, specifying the type of training provided and date.
- The IRO engaged has certified its professional independence and objectivity with respect to the mandated reviews and uses reviewers with current and nationally recognized coding certifications.
- The practice has no ownership, control interest, or other business interest in any third party billing company with whom they contract; and the practice certifies that it meets specified compliance standards enumerated in the CIA.