Mohler J W, Wolf J D
Laguna Medical Systems, Inc., San Clemente, CA, USA.
Healthc Financ Manage. 1998 Jul;52(7):62-4.
Many healthcare organizations avoid entering contingency-based arrangements with consulting firms that specialize in Medicare revenue optimization because they fear Federal investigation of such an arrangement might lead to a finding of fraud and abuse. A Medicare fraud alert issued by the HHS Office of the Inspector General (OIG) appears to justify that fear, suggesting that contingency arrangements are inherently unethical. Nonetheless, current Federal regulations clearly allow healthcare organizations to enter into contingency-based relationships with consulting firms to seek legitimate optimal payment. Healthcare organizations may do so without fear of Federal legal action if they ensure that the consultant is ethical and competent and that the DRG review process used is both legitimate and retrospective, subjecting all recommended changes to approval by both the healthcare organization and appropriate peer review organization.
许多医疗保健机构避免与专门从事医疗保险收入优化的咨询公司签订基于应急情况的协议，因为他们担心联邦政府对这种协议的调查可能会导致欺诈和滥用的认定。美国卫生与公众服务部监察长办公室（OIG）发布的一份医疗保险欺诈警报似乎证明了这种担忧是合理的，表明应急协议本质上是不道德的。尽管如此，现行的联邦法规明确允许医疗保健机构与咨询公司建立基于应急情况的关系，以寻求合法的最佳支付。如果医疗保健机构确保顾问是有道德且称职的，并且所使用的诊断相关分组（DRG）审查过程是合法且追溯性的，所有建议的变更都需经过医疗保健机构和适当的同行评审组织批准，那么它们这样做就无需担心联邦法律行动。
