Question

Indicate examples of provider self-disclosure

Answer 1

Ans) The Provider Self-Disclosure Protocol (SDP) provides guidance to providers who voluntarily decide to disclose irregularities in their dealings with Federal health care programs.

- The Provider Self-Disclosure Protocol is intended to facilitate the resolution of only matters that, in the provider’s reasonable assessment, are potentially violative of Federal criminal, civil or administrative laws.

- Matters exclusively involving overpayments or errors that do not suggest that violations of law
have occurred should be brought directly to the attention of the entity (e.g., a contractor such as a carrier or an intermediary) that processes claims and issues payment on behalf of the
Government agency responsible for the particular Federal health care program
(e.g., HCFA for matters involving
Medicare).

- The program contractors are responsible for processing the refund and will review the circumstances surrounding the initial overpayment.

- If the contractor concludes that the overpayment raises concerns about the
integrity of the provider, the matter may
be referred to the OIG.

- Accordingly, the provider’s initial decision of where to refer a matter involving non-compliance with program requirements should be made carefully.
- The OIG is not bound by any findings made by the disclosing provider under the Provider Self-Disclosure Protocol and is not obligated to resolve the matter in any particular manner.

- Nevertheless, the OIG will work closely
with providers that structure their disclosures in accordance with the Provider Self-Disclosure Protocol in an effort to coordinate any investigatory steps or other activities necessary to reach an effective and prompt resolution. It is important to note that, upon review of the provider’s disclosure submission and/or reports, the OIG may conclude that the disclosed matter warrants a referral to DOJ for
consideration under its civil and/or criminal authorities.

- Alternatively, the provider may request the participation of a representative of DOJ or a local United States Attorney’s Office in settlement discussions in order to resolve potential liability under the False Claims Act or other laws.

- In either case, the OIG will report on the provider’s involvement and level of cooperation throughout the disclosure process to any other Government agencies affected by the disclosed matter.