Is the Integrity Gap Widening in Behavioral Health?

It wasn’t too long ago that Behavioral Health received little attention with respect to integrity of our industry. However, with increased attention of the Department of Health and Human Services (DHS) and the Office of Inspector General (OIG), Behavioral Healthcare leaders, like other healthcare leaders, must re-examine their internal operations and practices to protect their organizations from fraud and abuse.

With Behavioral Healthcare billing millions and millions of dollars to Medicaid, Medicare and other healthcare programs each year, the growing attention received from the Federal Government is not likely to go away. Has fraud and abuse increased in the Behavioral Health Industry? We hear more and more about incidents occurring across the country including inaccurate claims, billing fraud and a range of unethical practices. Is the “Integrity Gap” widening in Behavioral Health?

The “Integrity Gap” refers to the “distance” between our day-to-day conduct and the ethical standards of the organization. If an organization operates unethically, the organization moves further away from its ethical code and widens the “Integrity Gap”.

To protect the integrity of the organization, the leader must be committed to establishing an internal compliance program to prevent fraud, abuse and other unethical practices. As leaders, we must insure a culture of integrity and manage the “Integrity Gap” within our organization.

To do so, we should develop compliance programs with internal controls to manage these risks. Effective compliance programs will consist of: 1) Statement of Conduct (organizational ethics), 2) Compliance Officer, 3) Compliance Hotline (insures anonymity of whistleblowers), and a process for 4) Internal Investigation.

Several high risk areas for abuse and fraud include inaccurate billing/claims, contractual relationships (internal/external), over-billing Medicare/Medicaid (In the past, it’s been reported that some financially struggling providers have used this technique to “float loans” to the organization until external audits require paybacks which in many cases don’t occur for several years).

Needless to say, internal controls with respect to inaccurate billing are essential in your compliance program as this is the area that receives the primary attention from external regulators. However other areas critical to the integrity of your organization should not be overlooked nor viewed as less important. Contractual relationships, Conflict of Interest, vendor/referral relationships, fundraising and so on – if mismanaged can seriously impact the integrity of your organization, widen the “integrity gap” and impact your ability to service your community.

Brown Consulting, Ltd provides Toll-free “Employee Action Line” to support your in-house Corporate Compliance Program. For additional information, call 800-495-6786.

Dan Brown, President