3 Steps: Drive Your Compliance Checkup Using the OIG Work Plan

Hayes picBy Robert Freedman, Hayes Management Consulting
Twitter: @HayesManagement

Nearly five billion dollars.

According to a report to Congress, that’s the amount returned to Uncle Sam in FY2014 as a result of healthcare oversight and investigations conducted by the Office of Inspector General (OIG). Avoiding this type of negative impact to cash flow and the bottom line is a matter of revenue integrity and is a high priority to most healthcare organizations.

The OIG Work Plan details areas of emphasis for their yearly compliance audit activities. Providers are encouraged to use the plan to prepare for potential audits. Using the Work Plan as a guide to review specific risk areas that impact your organization is the best way to create an effective compliance audit program and avoid paybacks.

Here are three steps to leveraging the OIG Work Plan to ensure the ongoing compliance health of your organization.

1. Triage

Using the OIG Work Plan in conjunction with a robust continuous compliance monitoring program is an effective way to assess the current risks for your organization. Many compliance programs identify key performance indicators that address the recognized OIG target areas. After you determine your organization’s applicable risk areas, you can track targeted data points, identify key objectives, and decide where your resources would be best deployed.

The final step in the triage process is setting up dashboards to track and report continuous monitoring activities. This highlights areas performing at or above your identified goals and those needing further examination. It’s important to remain flexible during this stage since issues needing further exploration can arise any time during the data-gathering phase.

2. Diagnosis

Examine your documentation and monitoring reports to define the extent of potential problems within your institution and to determine corrective action. Sampling reinforces or alters the potential problem areas discovered in the triage phase and auditing provides a deeper analysis into the operational issues.

One of the fundamental activities of the audit process is comparing the data collected from your internal systems to external benchmarks, rules, and professional standards to show how you stack up. This will help target areas that need additional focused efforts.

Most issues will be the result of a failure in either the areas of people, process, and/or technology. Determining the source of the problems will help formulate the type of action needed to mitigate or bring resolution to each issue.

3. Treatment

To correct issues resulting from human error, consider implementing a focused training program. Funding for training programs often loses the budget battle, but this can be shortsighted when considering the amount of federal reimbursement at risk from inadequately trained or unqualified staff.

Resolution of process related problems can be solved through modification of the process by those directly involved. Better documentation and training of institutional knowledge or eliminating a “that’s the way we’ve always done it” approach also helps. Every process should be thoroughly vetted by key staff members, documented in a centrally located repository, and integrated into every orientation and retraining program.

Technology related issues can result from faulty or inadequate use of the IT systems. The lack of data transfer between poorly integrated multiple systems can cause a “silo effect” where different teams and departments become isolated and valuable information goes unused. IT staff need to fully review the systems to ensure effective data transfer protocols to resolve this issue.

Other issues arise from inadequately trained staff failing to take full advantage of system capabilities such as automated edits, EMR “Smart” templates, and CDM. This can be solved through comprehensive orientation and annual staff updates of system capabilities.

The massive financial impact of the OIG High-risk Work Plan areas strongly suggests you have comprehensive risk based data improvement processes in place. The breadth and depth of the OIG Work Plan is overwhelming but it can’t be an excuse for inaction. Parse the report down to the portions most relevant to your organization and prioritize them to minimize their potential negative impact.

You are not going to be able to resolve all the problems outlined in the plan. However, you can focus on the ones that most affect you and that’s a great place to start.

This article was originally published in Hayes’ Healthcare Blog and is republished here with permission.