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OIG focusing on emergency department physician evaluation and management services

Angela Finnigan (angela.finnigan@ankura.com) is a Director at Ankura Consulting Group LLC in Amelia, OH; Marcella Jauregui (marcella.jauregui@ankura.com) is Director, Healthcare Risk, Privacy, Forensics and Compliance, at Ankura Consulting Group in San Francisco, CA; and Carla Starks (carla.starks@ankura.com) is Director, Healthcare Compliance, at Ankura Consulting Group in Chicago, IL.

The U.S. Department of Health & Human Services Office of Inspector General (OIG) conducts audits every year to ensure proper federal healthcare program payments are made. OIG remains at the forefront of the nation’s efforts to fight fraud in federal healthcare programs and hold wrongdoers accountable for fraud, waste, and abuse.[1] The audits are conducted based on risk areas identified by the OIG, which are put into a work plan. OIG has released its work plan for fiscal year 2022, which includes an audit of Medicare emergency department (ED) evaluation and management (E/M) services. In fiscal year 2020, OIG audits identified $566 million in expected recoveries and $920 million in potential savings for the Department of Health & Human Services programs.[2]

Performing audits that parallel the OIG work plan is imperative for healthcare organizations, as audits will identify areas of potential risks, avoid potential legal trouble or federal fines for noncompliance, and help promote the integrity of the organization’s compliance program. OIG repeatedly emphasizes in its guidance documents the importance of auditing and monitoring activities for an effective healthcare compliance program.

Routine audits should be conducted at least once annually, according to the OIG Hospital Guidance (and, of course, for-cause audits should be conducted as concerns are identified). A common method of assessing compliance program effectiveness is measuring various outcomes indicators (e.g., billing and coding error rates, identified overpayments, and audit results). Hence, organizations should develop detailed annual audit plans tailored to reduce risks associated with improper claims and billing practices.[3]

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