In fy2015, the Office of Inspector General (OIG) recovered more than $3 billion in audit and investigative receivables as a result of their oversight activities. That’s great news for U. S. taxpayers but not so wonderful for the many hundreds of provider organizations that had to dip into their shrinking revenues to come up with these repayments.
If you are among the many organizations that took a proactive approach to auditing by following the recommendations laid out in the OIG annual Work Plan, chances are you avoided that expensive fate.
Each year the OIG releases its internal Work Plan detailing areas of emphasis for their yearly compliance audit activities. Providers who begin to focus their audits on the risk areas the OIG has outlined sooner rather than later, stand a much better chance of addressing issues before they have a problem with government auditors. Following such a strategy allows you to self disclose overpayments and pay back the government prior to an official oversight audit. Even better, focusing on these high-risk areas early helps you avoid overpayment problems even before they occur.
The OIG has just released their 2016 Work Plan and have added a number of new review targets in the areas of hospital-based services, post acute care, lab testing, and Part D. It’s important not only to understand what the OIG will be looking for in these areas but also how you can incorporate and operationalize the revised Work Plan into your organization’s auditing activity.
New OIG focus areas
Hospitals – OIG auditors will be examining whether hospitals properly reported inpatient and outpatient claims for services that relate to replacement of defective medical devices. They will be looking for two claims for the same surgery and whether the second claim is for a replacement device that should be covered under a manufacturer’s warranty. They will also be looking at outpatient services payments provided during an inpatient stay when those services were included in Part A payments.
Skilled Nursing Facilities (SNF) – The OIG has added a more comprehensive audit of these facilities that could include an aspect of SNF billing that ensures that the documentation requirement for claims paid by Medicare was met. This documentation includes a physician order at the time of admission for the resident’s immediate care, a comprehensive assessment and plan of care from an interdisciplinary team. This new focus area was triggered by a study in September that suggested CMS should re-evaluate the SNF Medicare payment system.
Physicians – OIG will be combing through data to determine whether doctors have properly enrolled to order or refer services, supplies, or durable medical equipment in compliance with new regulations from CMS. Other areas of focus for physician ordering/referral include whether professional claims for anesthesia services are linked to a corresponding service, and whether doctors are properly billing for home visits and “prolonged” evaluation and management services.
Prescription Drugs – Auditors will be examining whether Medicare Part D beneficiaries are being prescribed drugs that should not be combined with other medicines.
Durable Medical Equipment – OIG will be reviewing Medicare Part B payments for orthotic braces to evaluate whether durable medical equipment, prosthetics, orthotics, and supplies to ensure that claims were medically necessary and supported according to Medicare requirements.
Using the OIG Work Plan
These are just a few of the many areas outlined by the OIG in the 2016 plan. It’s important to understand the key focus areas, but it’s even more crucial to build this information into your audit plan to stay ahead of potentially damaging audit findings.
There are three areas of your clinical operations that can benefit from the guidance provided by OIG.
Using the OIG Work Plan in conjunction with a robust continuous compliance monitoring program can be particularly effective in assessing the current risks in your organization. Many compliance programs identify key performance indicators that address the recognized OIG target areas. Determine your organization’s risk areas, track targeted data points, identify key objectives, and decide where your resources would be best deployed.
Set up dashboards to track and report on your 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.
Examine your documentation and monitoring reports to define the extent of potential problems within your institution and to develop 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.
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.
You can resolve many process related problems by modifying the process based on input from staff directly involved. Better documentation, training, and transfer of institutional knowledge or eliminating a “that’s the way we’ve always done it” approach can be effective solutions. 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 are often the result of 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.
Your ongoing battle to remain in compliance and avoid costly paybacks and penalties means using every tool at your disposal. The OIG Work Plan can be a valuable resource to help you get the upper hand in the fight. You’re not going to be able to resolve all the problems outlined in the plan but you can certainly focus on the ones that most affect you and that’s a perfect place to start.
This article was originally published on Hayes Management Consulting and is republished here with permission.