Early Evidence of Compliance Program Effectiveness Is Inconclusive

HEHS-99-59: Published: Apr 15, 1999. Publicly Released: Apr 15, 1999.

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William J. Scanlon
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Pursuant to a congressional request, GAO reviewed the compliance programs established by health care providers to reduce improper payments by Medicare, focusing on the: (1) prevalence of compliance programs among hospitals and other Medicare providers; (2) costs involved with compliance programs; and (3) effectiveness of the programs, to the extent that could be measured.

GAO noted that: (1) although there is no comprehensive data on the number of providers with compliance programs, many hospitals are implementing them; (2) two recent hospital surveys, one focusing on academic health centers and the other including a broad range of hospital types, found that most hospitals responding either had or planned to soon implement a compliance program; (3) the hospitals in GAO's study said they felt compelled to implement a compliance program for a variety of reasons, including the heightened enforcement environment, suggestions from the Department of Health and Human Services' Office of the Inspector General, and expectations that the Health Care Financing Administration and accrediting bodies would soon require compliance programs; (4) although compliance programs are apparently becoming widely accepted, most of the hospitals in GAO's study have only recently begun implementation; (5) hospitals report that compliance programs require an investment of considerable time and money; (6) however, measuring the cost of compliance programs is difficult; (7) hospitals could not always distinguish costs attributable to their compliance programs from those of their normal operations, in part because the hospitals often had existing compliance-oriented activities that were subsumed by the compliance program; (8) hospitals reported a variety of significant direct costs, such as salaries for compliance staff and professional fees for consultants and attorneys; (9) according to the information GAO was able to obtain, direct compliance program costs appear to account for a very small percentage of total patient revenues--less than 1 percent in all but one of the hospitals studied; (10) the hospitals also reported indirect costs, such as time spent by employees in compliance-related training and away from their regular duties; (11) these indirect costs are more difficult to measure and may be larger than the direct costs reported; (12) the principal measure of a compliance program's effectiveness is its ability to prevent improper Medicare payments; (13) it is difficult to measure effectiveness in this way because of the lack of comprehensive baseline data and the existence of many other factors that could affect measurement results; (14) other measures have been suggested as a proxy for measuring compliance program effectiveness; (15) Medicare contractors reported that they have received refunds of provider overpayments with more frequency; (16) GAO has also noted an increase in formal provider self-disclosures during the last few years; and (17) however, this preliminary evidence does not demonstrate that compliance programs have reduced improper Medicare payments.

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