Catherine Boerner (cboerner@boernerconsultingllc.com) is President of Boerner Consulting LLC in New Berlin, WI.
The Office of Inspector General (OIG) tends to have a reason when your hospital is included in one of its audits. The data mining and data analysis typically will be the reason you are on the radar. This is why compliance professionals need to be aware when the audit letters and result letters arrive. This puts your hospital on notice when there are errors to conduct reasonable diligence. Oftentimes these result letters explain what is expected, such as: “Please review the claims listing that is provided with this notification letter to determine whether overpayments exist and whether any similar overpayments exist within the six-year lookback period.” These result letters also explain the 60-day repayment rule when you identify errors.
For example, the Medicare Hospital Provider Compliance Audit reports explain:
Why OIG Did This Audit
This audit is part of a series of hospital compliance audits. Using computer matching, data mining, and data analysis techniques, we identified hospital claims that were at risk for noncompliance with Medicare billing requirements. For calendar year 2018, Medicare paid hospitals $179 billion, which represents 47 percent of all fee-for-service payments for the year.[1]
It also explains that: “OIG believes that this audit report constitutes credible information of potential overpayments. Upon receiving credible information of potential overpayments, providers must exercise reasonable diligence to identify overpayments (i.e., determine receipt of and quantify any overpayments) during a 6-year lookback period. Providers must report and return any identified overpayments by the later of (1) 60 days after identifying those overpayments or (2) the date that any corresponding cost report is due (if applicable). This is known as the 60-day rule.”[2]
The recent Medicare Hospital Provider Compliance Audits are looking at the following areas, so these are the areas to consider including in your annual compliance audit plan:
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Inpatient rehabilitation facility claims
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Inpatient claims billed with comprehensive error rate testing diagnosis related group codes
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Inpatient claims billed with high-severity level diagnosis related group codes
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Inpatient claims paid in excess of charges
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Inpatient claims paid in excess of $25,000
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Outpatient claims with bypass modifiers
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Outpatient claims paid in excess of $25,000
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Outpatient skilled nursing facility consolidated billing claims
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Outpatient home health agency consolidated billing claims
Other types of recent OIG audits include:
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Medicare Hospice Provider Compliance Audits
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Audit of Medicare Payments for Polysomnography Services
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Medicare Home Health Agency Provider Compliance Audit
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Audit of Medicare Payments for Eye Injections of Eylea and Lucentis
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Medicare Requirements for Reporting Cardiac Device Credits
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Medicare Improperly Paid Physicians for More than Five Spinal Facet-Joint Injection Sessions During a Rolling 12-Month Period