Data Analysis Points Hospitals to Higher-Risk Areas, Building on CMS, OIG Reports

When the HHS Office of Inspector General (OIG) put out a report on the growth in hospital billing for inpatient stays at the highest severity level, which it called “vulnerable to upcoding,” the compliance team at SSM Health dug into its own data.[1] What would it reveal about the nine MS-DRGs, including sepsis and chronic obstructive pulmonary disease, named by OIG as fueling an increase in Medicare spending nationally? To answer the question, “we pulled data for inpatient claims billed with high-severity-level DRGs,” said Shanna McKellip, senior data scientist in the SSM corporate responsibility department. “We also took it a step further and reviewed the length of stay and discharge dispositions to give it some context.” The data dive yielded some surprises. For example, sepsis DRGs had a short length of stay. “Typically, if you come into the hospital with sepsis you would expect a longer length of stay,” McKellip said. It turned out the shorter stays stemmed from either the deaths of patients or their discharges, which could put them at risk of readmission. “We determined we needed to do a full audit on these DRGs.”

But the data analysis, which is a core part of SSM’s compliance program, could have pointed in another direction. Sometimes it indicates an audit is unnecessary or that monitoring is an appropriate response, said Brigitte Doleshal, senior director of corporate responsibility at SSM, which owns 23 hospitals, physician offices, post-acute care centers and other entities in Missouri, Wisconsin, Illinois and Oklahoma.

“We run pretty lean as a compliance program. We want to spend time on the areas of highest risk,” Doleshal said. “We have always conducted a thorough risk assessment process, but this allows us to focus on areas of the highest risk to the organization.” Karye Morgando, system director of corporate responsibility, noted that risk assessment is now “a continuous cycle.”

McKellip, Doleshal and Morgando described the use of data analytics in developing risk assessments and work plans Feb. 25 at the Health Care Compliance Association’s virtual regional conference.[2] “Our goal is to review the data the way CMS does before CMS does,” McKellip explained. “It’s like having the answers to an open-book test.” The risks are described on risk briefs and rated by likelihood and impact on a heat map for senior leaders.

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