The OIG routinely publishes criminal and civil enforcement actions. There have been a substantial number of published cases so far this year related to documentation, coding and billing. Reviewing the summaries of these cases provides a valuable insight to compliance risk areas that may exist within your own organization. Based upon the pertinent facts, you can develop a list of potential risks and an audit work plan to mitigate the risk of similar behavior within your organization.
The actions that have been published since January 1 include:
- Falsifying medical records in order to bill for services not performed
- Billing for medically unnecessary services
- Up-coding
- Inappropriate unbundling of mutually exclusive procedure codes
- Violations of the Anti-kickback Statute
We recommend you review the criminal and civil enforcement actions on a regular basis to identify risks that are applicable to your organization and determine appropriate auditing, monitoring and other mitigating controls. In many cases, these steps will require you to rethink your auditing strategies. In the current, electronic documentation and coding environment, additional steps to ensure an effective compliance program are often required. These steps may include shadowing providers, reviewing documentation for reasonableness, in-depth training for coders and staff, and implementation of additional IT controls.
The complete listing of criminal and civil enforcement actions can be found at https://oig.hhs.gov/fraud/enforcement/criminal/index.asp