Physician Practice Corporate Integrity Agreements: What the Settlement Still Requires

Physician practice corporate integrity agreement violations have led to payments for late claims reviews, missing reports, failed exclusion screening and gaps in independent oversight. These are obligations that continue after a practice settles a case with the government. If you work in compliance, billing or practice management, you may know whether the promised review actually happened, what the reviewer received and what executives signed afterward. The settlement announcement tells the public what the practice agreed to do. You may know what happened next.

A corporate integrity agreement is a contract with the Office of Inspector General at the Department of Health and Human Services. It connects continuing obligations to civil healthcare settlements: the provider accepts compliance duties, and the agency agrees not to seek its exclusion from Medicare, Medicaid and other federal health care programs. The work includes independent reviews, training, screening and reports to the government.

What Integrity Agreements Change Inside a Practice

An integrity agreement assigns people to work that can be checked later. We expect that work to protect patients and taxpayers, whose interests outlast the settlement announcement. At Physician Partners of America, the five-year agreement requires a chief compliance officer, deputy compliance officers, a medical director, a compliance committee and a compliance and clinical oversight board. The chief compliance officer reports directly to the chief executive and cannot be subordinate to the chief financial officer or general counsel. The committee includes the functions that can affect a claim, including billing, clinical operations and human resources.

That arrangement matters in a physician business where the management company and the clinical practice can hold different parts of the operation. The professional entity supplies clinical services while a management services organization supplies contracted administrative functions. Ownership and operating control can sit in different hands. A compliance officer needs access to the people controlling the relevant work, wherever they sit on the organization chart.

Advanced Urology’s agreement with the inspector general makes that division explicit. It covers Advanced Management Solutions for the services it provides to Advanced Urology, and allows the integrity obligations to be carried out by the manager or the practice as appropriate. Its written standards, training plan, disclosure program and screening duties therefore have an operating home beyond the examination room.

Independent Review Reaches the Care Behind the Claim

Independent review under these agreements examines whether the care was medically necessary, whether the documentation supports it and whether the claim was correctly coded and paid. The independent review organization must also assess its own independence and disclose its current and prior engagements with the practice. Those are separate questions: whether the claim stands up, and whether the reviewer can examine it objectively.

Physician Partners of America Follows the Test Order

Physician Partners of America’s agreement reaches Medicare and Medicaid claims, including managed care payments. Its annual review covers selected practice locations, with a random sample of 100 paid claims at each selected location. When a sampled claim reveals an overpayment, the reviewer must examine the systems and processes that generated it and recommend improvements. That takes the inquiry from an individual bill back into the way the practice works.

The agreement also requires a testing report recording the test, patient, ordering provider, date and clinical reason. Monthly review by the compliance officer and medical director examines ordering patterns and medical necessity. Quarterly review also looks for providers who have not regularly reviewed test results and acted on them in patient care. That last requirement gets to the point: ordering a test creates a bill, but what did the result do for the patient?

The Justice Department’s settlement announcement alleged unnecessary urine, genetic and psychological testing, among other conduct. The agreement’s focus on orders, results and clinical decisions follows that alleged mechanism. A clinician who knows why the test was ordered can explain something a billing code alone cannot.

Advanced Urology Follows the Sample and the Missing Chart

Advanced Urology’s five-year agreement requires an annual random sample of 100 Medicare fee-for-service paid claims. The review tests medical necessity and documentation as well as coding. The agreement also specifies what happens when the practice cannot produce the supporting record: the claim counts as an error and its reimbursement as an overpayment.

The practice cannot replace an undocumented claim with another sampled claim. The reviewer must use the first random sample drawn. If it accepts extra documentation after completing its initial review, the report must explain what arrived, when it arrived, why it was accepted and how much weight it received. Someone who saw the original chart and the later submission may know exactly what changed between them.

A San Antonio Oncology Agreement Reaches the Outside Biller

The integrity agreement for a San Antonio oncology physician and practice has a three-year term. It also requires annual review of a random sample of 100 Medicare fee-for-service paid claims, examining medical necessity, documentation and coding. Its compliance contact cannot have separate duties involving billing, coding or claim submission, or oversight of those functions.

If the practice uses an outside billing company, the agreement requires certifications about that relationship. The practice must certify that it has no ownership or control interest in the biller. The biller must certify its policies against employing excluded people in claims work, its employee screening and its training. Outsourcing the claim creates another set of representations the government can examine.

The agreement treats employees of a third-party billing company differently from the practice’s own staff. They fall outside its covered-person definition when the practice and billing company provide the required certifications. That makes the certification file particularly useful to someone who knows who actually prepared and submitted the claims.

Executive Certifications Need Work Behind Them

Executive certification under these agreements ties a signature to responsibility for the work. At Physician Partners of America, the certifying roles include senior executives and department heads. They must monitor their areas and certify compliance annually. The oversight board must describe the materials it reviewed and the steps behind its own compliance resolution.

Advanced Urology also requires certifications from senior executives and department heads. Its agreement requires a written process identifying the reports, assessments and supporting certifications those people need before signing. The annual report also requires certifications from the management company’s chief executive, the compliance officer and the physician identified in the agreement. The San Antonio agreement places its annual certification with the compliance contact and chief executive.

Advanced Urology reported in the agreement that it had no board, so its owners would perform the board’s duties. Those duties include quarterly review of the compliance program and describing the materials examined before adopting an annual compliance resolution. For an insider who raised a billing concern, the owners’ review is another place where that concern and the response may appear.

We look at what stood behind the signature. A claims-review report, a department’s supporting certification and the correction discussed in a management meeting can explain what the signer knew. At Advanced Urology, the agreement even requires a written explanation when a responsible executive cannot provide the certification.

The chapter Implementing a Physician Practice Compliance Program, published in Health Care Administration: Managing Organized Delivery Systems by Jones and Bartlett Publishers in 2011, explains the management problem behind these duties. It argues that responsibility needs matching authority:

The chapter also describes the conflict when a small practice’s billing supervisor audits their own work and the physician’s billings. That is the practical value of independent review and direct access to decision-makers: the person expected to identify a problem needs room to challenge the people generating it. A compliance title without that authority leaves the central problem in place.

Reporting Deadlines Leave a Dated Trail

Reporting deadlines make the practice’s response traceable. All three agreements require notice to the inspector general within 30 days after determining that a reportable event exists. Their definitions include substantial overpayments, probable violations affecting federal health care programs, and employment or contracting with an ineligible person. The determination and the report are distinct events, with records behind each.

The first implementation report is due within 120 days under the Physician Partners of America and Advanced Urology agreements, compared with 90 days under the San Antonio agreement. Advanced Urology’s first annual report is due within 60 days after its first reporting period ends. Its disclosure log must record the concern, who received responsibility for reviewing it, the review’s status, corrective action and resolution date. That trail can connect an internal concern to what management later reported.

The independent reviewer and the practice must retain working papers, supporting documents, correspondence and draft reports exchanged during the review. Advanced Urology’s agreement also requires retention of reimbursement and compliance records for six years from its effective date. The final report is one part of that history. The drafts and supporting records can explain how its conclusions took shape.

Actual Integrity Agreement Violations and Paid Penalties

The inspector general has recorded payments for failures to carry out these kinds of obligations. The entries below identify the separate penalties and the duties breached:

The missed duties reach different parts of the practice: the reviewer doing the checking, the staff completing training, the people screening workers and the person sending the report. At Sarasota Pain Associates, the entries move from implementation failures to a quarterly claims review and then an annual report. The settlement still left recurring work to do, and these later payments concerned failures in that work.

Potential penalties appear separately in the contracts. Advanced Urology’s agreement allows the agency to assess up to $2,500 per day for specified failures, including review obligations. The San Antonio agreement allows up to $50,000 for a false certification or false statement to the agency. These are potential assessments under those agreements. The table records payments for breaches by other practices.

The Settlement and the Breach Concern Different Conduct

Sarasota Pain Associates and its physician agreed to a $750,000 settlement announced in February 2014. The Justice Department alleged high-level office-visit billing for comprehensive examinations that did not occur, on top of separately paid procedures. Former nurses brought the whistleblower case. The resolution included a three-year integrity agreement, independent external review and training.

The later quarterly-review payment in the table was a fraction of that office-visit upcoding settlement. We find the promise harder to square with what followed: independent review was part of the resolution, yet the practice was later penalized for a late review report.

The North Carolina oral surgeon’s 2015 civil settlement required $2.2 million to resolve disputed Medicaid billing claims involving oral evaluations, sedation, nitrous oxide and alveoloplasty. The later integrity-agreement payment concerned hotline, training, screening and reporting failures. A compliance employee may know about those failures, while a clinician or biller can explain the services and claims.

What Evidence Does a Whistleblower Need?

A whistleblower’s useful evidence connects the obligation, the person responsible, the work performed and what the practice told the government. An agreement and its review requirements give an engagement letter, claims sample, draft report, training record or executive certification its meaning. Someone who worked on those records may be able to explain a missing review or a conclusion that changed after management intervened.

If you saw management keep money after a review identified false Medicare claims, bring that knowledge to us. We examine what the review found, what management knew and what happened to the money when assessing a potential False Claims Act case.

For false billing, that account also connects to the actual claim and the care behind it. The patient chart, service date, practitioner, code and payer help explain what the government paid for. We work with insiders to assess that connection and bring in physician fraud whistleblower lawyers who understand both the billing and the post-settlement obligations.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. We help you shape your strongest physician practice whistleblower case from what you know about the agreement, the review and the claims.

When You Know What Happened Afterward

If you worked on the review, the certification or the claims and know the practice told a different story, speak to our physician fraud whistleblower experts about what the practice skipped and what it signed. We help you build a case strategy around what you saw, bring in whistleblower lawyers experienced in physician billing and integrity agreements, and stay beside you through the decisions that follow.