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Is your organization prepared for the coming audit storm?

Vasilios Nassiopoulos (vnassiopoulos@hayesmanagement.com) is Vice President of Platform Strategy and Innovation at Hayes Management in Wellesley, MA.

Regulators had already intensified and expanded the scope of their auditing road map before COVID-19 entered the US. In late 2019, U.S. Department of Health & Human Services’ Office of the Inspector General (OIG) recommended that the Centers for Medicare & Medicaid Services (CMS) direct its contractors to recover $54.4 million in improper payments to acute care hospitals due to incorrectly coded claims.[1]

Further intensifying its ongoing efforts, the OIG added auditing of COVID-19 incentive payments to its Work Plan in August 2020[2] while simultaneously increasing compliance risk by requiring a positive test result for the higher inpatient payment.[3] While the latter was unpredictable, there is no reason the industry should be surprised by the incentive payment audits—an increased layer of oversight that is expected to continue to evolve and present significant revenue integrity challenges in 2021.

The stakes at play within the current audit climate are not lost on today’s C-suite. A recent survey of healthcare chief financial officers and revenue cycle leaders revealed considerable confusion and concern over coding and claim requirements.[4] Increased workloads related to COVID-19 claims—a factor that will continue to pose challenges—was also named a top issue, second only to erratic and unpredictable claim volumes.

Heightened regulatory scrutiny naturally leads to the need for optimal approaches to revenue integrity, a growing best practice that maximizes revenue capture while ensuring the highest level of compliance. Healthcare executives are wise to consider key areas of risk and shore up compliance and billing strategies.

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