Medicare administrative contractors (MACs) are reopening hospital claims based on information from the HHS Office of Inspector General (OIG) before there’s an overpayment finding, an OIG official said.

“MACs have now started reopening claims when we initiate an audit,” said Michael Ira Joseph, an OIG senior counsel. “They do this relying on our risk assessment.” The risk assessment includes a Hospital Compliance Dashboard that helps OIG choose hospitals for a compliance audit.^[1] “We have data for all the hospitals and we can see where a hospital may be an outlier with respect to certain types of claims,” he said at the HCCA Compliance Institute April 17. “There’s a reason why we choose hospitals to audit, and MACs are now relying on that and issuing reopening notices to providers when we begin an audit.”

Joseph and two other OIG officials explained the audit process and their responses to complaints from hospitals about some aspects of provider audits, including the use of an independent medical reviewer and extrapolation.

Hospitals may encounter two types of audits, said Truman Mayfield, assistant regional inspector general. One is an audit specific to the provider that covers multiple risk areas at the same time from a list of 32 potential inpatient and outpatient risk areas. The other type is an issue-specific audit, with OIG focusing on CMS or one of its contractors, although the hospital could be contacted, and an issue-specific audit could lead to a provider-specific audit.

Hospital compliance audits, which started in 2010, have identified $90 million in actual overpayments and $304 million in extrapolated overpayments, Mayfield said. They’re a “significant portion of our Medicare Part A workload” and “will continue to be in the future.”