Ethics, Fraud, and Internal Audit at Ut Southwestern

There are many taxpayer supported medical schools in this country, most receiving their fees for services through Medicare and Medicaid. The Department of Health and Human Services requires that medical students who have graduated to the resident status have a teaching physician physically present when performing key portions of patient service to be able to bill those services to Medicare. In fact, the patient chart must be legibly signed by the attending physician that they were present and supervising the specific service in order to bill Medicare (“Guidenlines for teaching,” 2011).

According to an article in the Dallas News, a former employee by the name of Jack Mooney was hired in 1991 by the University of Texas Southwestern Medical Center as a reimbursement manager to make sure that all medical billings submitted to Medicare and Medicaid were properly documented and billed (Dunklin & Moffeit, 2010). For example, that the teaching physicians were physically present when residents were performing services to meeting the required mandates for Medicare billing. He discovered that was not the case and took the information to his supervisors.

Stricter policies were put into place for the departments to follow to make sure that all employees were following the necessary guidelines. In 1997, when Mr. Mooney was the director of UT Southwestern’s billing compliance office, he was still seeing and documenting the same problems. Mooney left the college in 1998 shortly after filing a federal whistle-blower lawsuit. The earliest documentation that can be found of UT Southwestern’s Internal Audit departments involvement comes in a 2003 when they approve of some of the college’s compliance policies, but noted that they do not have a policy in place to review reimbursement claim documents.

Dallas News notes that six faculty meetings were held during 2007 and 2008 in which billing concerns were discussed. The Internal Audit Annual Reports for those years do not report any ongoing audits, but do report that they provide the billing compliance committee “independent consultation and guidance to help billing compliance activities address institution risks” (Rubel, 2008). In 2010 we finally see an internal audit performed of UT Southwestern’s billing compliance programs. The report stated that “the audit identified a significant finding in the Hospital Billing Compliance program”.

As of 2010, the program had not yet implemented the 2005 Department of Health and Human Services, Office of the Inspector General (OIG) Supplemental Compliance Program Guidance for Hospitals. Although this guidance is voluntary, it is highly recommended by the OIG to help hospitals in “preventing the submission of erroneous claims and in combating fraud and abuse in the Federal health care programs (“OIG supplemental compliance”). The guidance specifically states that “hospitals should have in place procedures regarding resident rotation and monitoring”.

The audit report recommends that the compliance program implement the OIG guidance, consolidation of the billing compliance groups (there are currently four), development of a single risk assessment plan with a corresponding audit plan, a monitoring system for both the risk assessment audit plan and the billing compliance audit report. Also of note in the audit report are repeated failures by the same department to meet billing practices. It is noted that these “recurring systematic failures increase the risk of exposure to potential civil damages and penalties, criminal sanctions, and administrative remedies, such as program exclusion”.

The audit recommends that the failures be addressed at the department level and to develop a formal training plan to improve billing compliance. According to the report, all significant findings are tracked by the University of Texas System Audit Office to make sure that all agreed upon recommendations have been implemented. These reports are unavailable for review and there has been no further comment on the billing compliance audit in the 2011 Internal Audit Annual Report. This issue was first brought to light 20 years ago by someone that was hired to review billing compliance.

We know that 7 years ago the internal audit department was aware of the issue, but as far as we can tell, no significant audit of the hospitals billing department, in relation to Medicare billing requirements, was completed until 2010. Was the hospital fraudulently obtaining money from the government? Not in so far as anyone has determined. Was the audit department aware of the issue? Yes, as far as we can tell. Did the internal auditors follow the IIA’s mandatory guidance? Yes in the completion of the audit in 2010 but it is my personal opinion, given the facts provided, that the audit should have been ompleted years earlier. ?

References Department of Health and Human Services, Centers for Medicare & Medicaid Services. (2011). Guidenlines for teaching physicians, interns, and residents. Retrieved from website: http://www. cms. gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/gdelinesteachgresfctsht. pdf Department of Health and Human Services, Office of Inspector General. (n. d. ). OIG supplemental compliance program guidance for hospitals (Vol. 70, No. 19). Retrieved from website: http://oig. hhs. gov/fraud/docs/complianceguidance/012705HospSupplementalGuidance. df Dunklin, R. , & Moffeit, M. (2010, May 30). Feds probe alleged fraud at ut southwestern, parkland. Dallas News. Retrieved from http://www. dallasnews. com/news/community-news/dallas/headlines/20100530-feds-probe-alleged-fraud-at-ut-southwestern-parkland-. ece Rubel, R. (2008, November 03). Internal audit annual report fiscal year 2008. Retrieved from http://www. utsouthwestern. edu/media/footer_required_documents/audit-2008. pdf Rubel, R. (2010, February 24). Billing compliance audit report. Retrieved from http://res. dallasnews. com/localnews/responsivedocs_audit_2010. pdf