SYSTEMIC WEAKNESS REPORTS
SYSTEMIC WEAKNESS REPORTS
DEFINITION
During the course of investigating and prosecuting health care fraud, systemic weaknesses or vulnerabilities to fraud, waste, abuse or mismanagement are sometimes discovered in health care benefit programs.¹ A systemic weakness is one that is judged to be a fundamental problem that requires corrective action through administrative, regulatory, legislative or policy change. A systemic weakness report should be prepared whenever a policy, procedure or systems process fails to prevent, detect or minimize losses due to fraud, waste, abuse or mismanagement in health care benefit programs.
PURPOSE
The purpose of the systemic weakness reporting system is to assist in the effective prevention and detection of health care fraud. Systemic weakness reports are designed to provide a mechanism to alert program managers at the national level to such weaknesses and vulnerabilities so that corrective action can be taken. Systemic weakness reports received from United States Attorneys offices, the Department of Justice and the Federal Bureau of Investigation should be submitted to the Civil Division, which will identify issues of national significance and make referrals to the appropriate departments or agencies to enable corrective action to be taken.
The Department of Justice encourages Assistant U.S. Attorneys, litigating Division attorneys, and Federal Bureau of Investigation agents who believe that they have identified a systematic weakness to contact the program(s) affected to explore the issue prior to submitting a systematic weakness report. Early contact with the program should help the program identify any systematic weakness, aid in reporting systematic weaknesses, and may clarify for the Department of Justice personnel whether there is, in fact, a systematic weakness.
PREPARATION
1. Time for Submission
The systemic weakness reporting process supplements case investigation and prosecution responsibilities of Assistant United States Attorneys, litigating division attorneys, and Federal Bureau of Investigation agents. At the conclusion of each health care case, a routine review of the matter should be made to and assess whether a systemic problem exists. If a systemic problem is identified, a systemic problem report is to be made using the format that follows.
However, preparation of the systemic weakness report need not await the completion of an ongoing case investigation, but should be submitted as soon as possible after the systemic problem is detected. In these circumstances, the report should be written generically so that specific case information is not disclosed. In addition, a report need not be related to any specific case investigation. Timely reporting is critical to the success of this reporting program.
2. Format
The systemic weakness report should provide a brief description of the problem, and include sufficient detail to permit cross-referencing to other such reports. To the extent possible, the factual summary should:
a. identify the problem including, where relevant, specific codes, procedures or diagnoses which are being misused;
b. describe how the problem was discovered;
c. describe the case or investigation as it relates to the systemic problem, including the type(s) of provider(s) and, if
applicable how the provider(s) actions compromised the program;
d. if possible, estimate the scope and frequency of the problem in the region/area, including available statistics on
overpayment amounts, volume, and percentages;
e. if possible, describe the condition(s) which enabled the problem to occur. An example would be failure or absence of
internal or external controls to detect, prevent or minimize the vulnerability. If available, cite applicable regulations,
policies, and manual provisions which relate to the problem; and
f: describe contact made with the program(s) affected (if any) to identify and discuss the systematic weakness. Identify the
dates of any contact and the participants. Attach copies of relevant correspondence or memoranda relating to such
contract.
PROCESSING PROCEDURES
Assistant United States Attorneys and trial attorneys should forward their reports to the Civil Division through their health care fraud coordinators. Federal Bureau of Investigation reports should be forwarded to the Health Care Fraud Unit at FBI headquarters. All Department components will forward the reports to the Civil Division which in turn will forward them to the Department of Health and Human Services Office of Inspector General, and other offices as appropriate. The Civil Division will inform the originating office of any responses received and prepare periodic narrative summaries of all such reports and results.
SPECIAL RECOGNITION
The Deputy Attorney General, the Assistant Attorney General for the Civil Division, or their designees, will give special recognition to the originators of outstanding systemic weakness reports.
HEALTH CARE FRAUD INVESTIGATIONS GUIDE
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SYSTEMIC WEAKNESS REPORTS
SYSTEMIC WEAKNESS REPORTS - These reports are designed to provide a mechanism to alert program managers at the national level to systemic weaknesses and vulnerabilities in health care benefit programs, as defined in 18 U.S.C. § 24(b), so that corrective action can be taken. A systemic weakness is one that is judged to be a fundamental problem that requires corrective action through administrative, regulatory, legislative or policy change. A systemic weakness report should be prepared whenever, during the course of investigating or prosecuting health care fraud, it appears that a policy, procedure or systems process in a health care benefit program has failed to prevent, detect or minimize losses due to fraud, waste, abuse or mismanagement. Systemic weakness reports received from United States Attorneys offices, the litigating Divisions and the Federal Bureau of Investigation will be submitted to the Civil Division to ensure that issues of national significance are identified and referrals are made to the appropriate departments or agencies to enable corrective action to be taken.