Case Study:

Corporate Integrity Agreement and a Skilled Nursing Facility Provider


The Circumstances and Challenges

A large, regional owner/operator of skilled nursing facilities had entered into a corporate integrity agreement (“CIA”) with the Office of Inspector General, Department of Health and Human Services.  As often is the case, one of the terms of the CIA was the engagement of an Independent Review Organization (“IRO”).

Selecting an IRO and the Engagement Process

The provider approached The Fox Group, LLC  to perform the duties of the required IRO, as outlined in the CIA, for a period of five years.  Under the terms of the CIA, the IRO would be required to perform an in depth analysis of 500 paid claims.  On an annual basis, our team of six healthcare professionals were brought on-site, to perform the requisite audits.  These onsite visits lasted for a full week.

On a daily basis, “mini-exits” were conducted to communicate preliminary findings to the provider’s designated compliance team.  In addition, an introductory entrance conference was held with the provider to orient them to our approach to the audits, as well as expectations for the week.  At the end of the week, there was a wrap up exit conference that covered our general findings and what the provider could expect to happen going forward.

The Outcome, Reporting, and Compliance

The Fox Group was able to work very successfully and cooperatively with the provider to perform the required duties outlined in the CIA.  Each onsite visit went smoothly. The provider demonstrated compliance, made adjustments,  resulting in The Fox Group, LLC, as the selected IRO, to provide a report and document an error rate within the acceptable range. The Fox Group was able to submit the reports and documentation to the provider on a timely basis so that the required annual report could be completed and submitted to the OIG.  After a period of five years, the provider was released from the CIA.


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