Healthcare Internal Investigations

Healthcare fraud, waste, and abuse have been an ongoing concern in the healthcare industry. These practices not only undermine the integrity of the healthcare system but also jeopardize the safety and wellbeing of patients. In response to this, healthcare organizations need to have a robust compliance program that includes internal investigations to detect and prevent fraud, waste, and abuse. In this article, we will discuss the importance of healthcare internal investigations and the role they play in mitigating fraud, waste, and abuse. We will also cover the Department of Justice guidance on the requirement for investigating, the investigation process, and the necessary action to take after an investigation.

Department of Justice Guidance

The Department of Justice (DOJ) has made it clear that healthcare organizations must have an effective compliance program that includes internal investigations. The DOJ's guidance emphasizes the importance of self-reporting and cooperation with government investigations, and failure to do so can result in significant penalties and fines. The DOJ guidance sets forth seven elements that must be present in an effective compliance program, and one of these elements is internal investigations. The DOJ states that a healthcare organization's compliance program must provide for the "timely, thorough, and effective investigation of potential misconduct."

Why Healthcare Internal Investigations are Necessary

Internal investigations are a crucial component of a healthcare organization's compliance program. When there is a report of suspected fraud, waste, or abuse, an investigation is necessary to determine the validity of the report and identify any misconduct. An internal investigation can also help to mitigate any potential risks to the organization, its employees, and patients. An investigation can also help to demonstrate the organization's commitment to compliance and integrity.

The Investigation Process

The investigation process typically starts with an allegation or suspicion of fraud, waste, or abuse. The investigation team should consist of trained investigators who are knowledgeable in healthcare compliance and regulations. The investigation team should be independent, and the organization's management should not interfere with the investigation process.

The investigation process may involve collecting documents and data, interviewing witnesses and employees, and analyzing financial records. The investigation team should follow a set of procedures and protocols to ensure that the investigation is thorough and impartial. The investigation team should also maintain confidentiality to protect the privacy of individuals involved.

After the investigation is complete, the findings should be reported to the appropriate authorities, such as the DOJ or Office of Inspector General (OIG). The organization should also take necessary action to address any findings of misconduct and implement measures to prevent future occurrences.

Action after an Internal Investigation

If the investigation determines that fraud, waste, or abuse has occurred, the organization must take appropriate action. This may include disciplinary action against employees involved in the misconduct, repayment of any funds obtained fraudulently, and implementing measures to prevent future occurrences.

The organization must also report the findings to the appropriate authorities, such as the DOJ or OIG. Failure to do so can result in significant penalties and fines. The organization should also review and update its compliance program to prevent future occurrences of fraud, waste, and abuse.

Lets Get Your Practice Compliant

An effective healthcare compliance plan is essential in preventing and detecting fraud, waste, and abuse. The compliance plan should include policies and procedures that outline the organization's commitment to compliance and its expectations for employees. The plan should also provide a mechanism for employees to report suspected fraud, waste, and abuse.

The compliance plan should also include provisions for conducting internal investigations. The plan should specify the roles and responsibilities of the investigation team and outline the procedures for conducting investigations. The plan should also outline the reporting requirements and the actions to take after an investigation.