Compliance Program Recommendations – From an IRO’s Perspective

Corporate Integrity Agreements (CIA) are mandatory compliance programs which are used by the Office of Inspector General (OIG) as a mechanism to enforce compliance within organizations who have entered into false claims settlements.  The required compliance program elements contained within a CIA typically mirror those within the OIG’s Compliance Guidance and the Federal Sentencing Guidelines.  One of the new unique components of a CIA when compared to a standard compliance program is the requirement to engage an Independent Review Organization (IRO).  HBE has served as an IRO for over a decade and has conducted compliance related investigations for over 20 years.  Through our years of experience, we have observed common problem areas that face providers.  We will be highlighting these areas over the next several weeks in our Compliance Program Recommendations Series with the intention of raising awareness and providing valuable recommendations to improve your compliance operations. 

One of the biggest challenges providers encounter is obtaining accurate data.  The ability to generate reliable data is crucial to many compliance functions and can impact the integrity of monitoring through data analysis and the validity of audit sampling as well as an extrapolation of overpayments.  In the setting of a CIA or the 60-day rule, the ability to access data quickly and have confidence in the data integrity is critical.  There are many factors that can impact your ability to extract data in a meaningful way.  Factors that often hinder this process include inherent system reporting limitations to suboptimal charge and payment posting processes.   

There are essential data points that you should be able to query and generate custom reports from within a quick timeframe.  These data points include:

  • Unique patient identifier
  • Rendering Provider
  • Billed Provider
  • From/Through Dates
  • Date of Service
  • CPT/HCPCS code
  • Modifiers
  • Line item charge by CPT/HCPCS
  • Primary Payor
  • Line item primary payment by CPT/HCPCS
  • Secondary Payor
  • Line item secondary payment by CPT/HCPCS

CIAs and overpayment investigations often necessitate the need to select a sample of paid claims and calculate an overpayment amount for a specific code(s) for a specific provider and specific time period.  We often find in order to obtain that level of detail, the preparation of a custom report is often required and generally entails having to make a request to your software vendor.  This process can be time and resource intensive which can cause difficulties meeting government mandated deadlines.  We also find many organizations choose to batch post payments rather than post line item payment detail.  This process creates certain efficiencies however, it makes it virtually impossible to create a universe of claims that contains accurate payment information. 

Discovering you cannot generate or access accurate data while in the midst of a CIA review or investigation is an unwelcome problem that providers cannot afford.  The best course of action is one of being proactive.  Compliance should work collaboratively with IT to determine the reporting capabilities that are available and whether the need exists to request custom report functions.  It is equally important to not only run “test” reports but to assess the validity of the data you are able to retrieve.  This means comparing line items from your data query to actual remittance advice documents to determine the accuracy and limitations of your data queries.  Finally, assess whether key processes need to be revised in order to generate accurate data down the line.

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