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IRO Services for providers under a CIA with the OIG

Compliance, Fraud, Waste & Abuse

IRO Services for providers under a CIA with the OIG

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IRO Services for providers under a CIA with the OIG SFUR has the qualifications and experience to provide Independent Review Organization (IRO) Services to health care providers Corporate Integrity Agreements (CIAs) with the Office of Inspector General of the United States Department of Health and Human Services (OIG) and the related Settlement Agreements entered into with the United States.

Summary

The benefit to the provider and hospital is that they remain in compliance with the CIA and that they receive the feedback and training to remain in compliance with Medicare rules and regulations. SFUR offers these services at competitive rates.

SFUR has experience providing the services for CIAs, IRO matters and the subject matter relevant to healthcare provider’s CIA. SFUR’s 600 physician panel deals with health care fraud and abuse issues, IRO services, compliance readiness assessments, government investigations and health care compliance.

Since the 2016, SFUR has provided services in connection with over CIAs, submitting IRO quarterly and annual reports to the OIG. Our team comprises specific professionals with backgrounds in compliance, medical coding, forensic audit and government investigations data analytics, information technology and computer forensics. We have a proven record of high-quality service, reliability and objectivity.

SFUR’s combination of experience and competencies makes SFUR an ideal firm to serve as your IRO services provider.

SFUR deploys the following team members as needed to serve your IRO needs.

  • Professional coders who hold nationally recognized health information management and coding credentials through the American Health Information Management Association (AHIMA) and the American Academy of Professional Coders (AAPC)
  • Board-certified physicians within numerous specialties who are Utilization Review Accreditation Commission (URAC) compliant
  • Professionals with previous US Government enforcement experience (e.g., the OIG and various US attorneys’ offices) that directly related to audits, investigations and prosecution of entities related to relevant laws and regulations, including Medicare and Medicaid laws and regulations, Stark Law and Anti-Kickback Statute, as well as Food, Drug and Cosmetic Act, among others
  • Professionals with significant experience helping clients assess and address current and emerging compliance risks, such as claims submission issues under the False Claims Act and contractual and non-contractual relationships implicated under the Anti-Kickback Statute
  • Professionals with demonstrable experience in substantial aspects of voluntary compliance drawing on our experience in process improvement, controls development, audit and monitoring, financial transaction analyses and project management

Example

Hospitals and Doctors can enter into a Corporate Integrity Agreement (CIA) with the Office of Inspector General (OIG) promote compliance with the statutes, regulations, and written directives of Medicare, Medicaid, and all other Federal health care programs (as defined in 42 U.S.C. § 1320a-7b(f)) (Federal health care program requirements). Contemporaneously with this CIA, Hospitals and physicians enter into a Settlement Agreement with the United States. Typically these physicians and hospitals may have overpaid Medicare and they have been subjected to settlement whereby they have to repay the Medicare.

SFUR, because of its Independent Review Organization (IRO) status provides various audit and compliance services to these hospitals and physicians. For example SFUR has performed numerous Inpatient Medical Necessity and Appropriateness Reviews where as an IRO they 1: evaluate and analyze the hospital’s inpatient admissions and relevant length of stays to determine if such admissions and length of stays were medically necessary and appropriate under the applicable Federal health care program rules and regulations governing inpatient admission, treatment, discharge, billing, and reimbursement, and (2) determine whether the claims submissions to Federal health care programs associated with each inpatient admission were documented, coded, and billed appropriately (Inpatient Medical Necessity and Appropriateness Review). As the IRO, SFUR prepares an Inpatient Medical Necessity and Appropriateness Review Report.These reviews can be performed quarterly or yearly.