The OIG recently released three new hospital compliance audit reports. The audits, which focused on both outpatient and inpatient claims, from 2016-2017 resulted in findings of $926,758 in actual overpayments with extrapolated overpayments of $6.7 million. The reports highlight ongoing hospital compliance risks with documentation, coverage and coding and the need for continued focus. In their reports, the OIG outlined recommendations to improve hospital accuracy and compliance. The HBE team is available to assist you with performing the OIG recommendations including:
- Conduct auditing and monitoring of the identified risk areas
- Strengthen processes to ensure medical necessity and coverage criteria are met for identified risk areas, with particular attention to short stay admissions and inpatient rehab
- Provide documentation and coverage training for clinical and administrative staff related to the identified risk areas
- Provide coding training for health information and administrative staff related to the identified risk areas
We have summarized the findings of the three compliance reports.
| SAMPLE RESULTS BY RISK AREA | |||
| RISK AREA | SELECTED CLAIMS | CLAIMS WITH OVERPAYMENTS | ERROR PERCENTAGE |
| INPATIENT PSYCHIATRIC EMERGENCY ADJUSTMENTS | 32 | 24 | 75% |
| IRF CLAIMS | 90 | 42 | 47% |
| HIGH SEVERITY DRGS | 23 | 9 | 39% |
| INPATIENT CLAIMS PAID IN EXCESS OF CHARGES | 3 | 1 | 33% |
| PRESENT ON ADMISSION INDICATORS | 7 | 2 | 29% |
| CERT HIGH ERROR RATE DRGS | 75 | 21 | 28% |
| INPATIENT ELECTIVE PROCEDURES | 67 | 4 | 6% |
| MECHANICAL VENTILATION | 1 | 0 | 0% |
| SAME DAY DISCHARGE AND READMIT | 2 | 0 | 0% |
| INPATIENT TOTALS | 300 | 103 | 34% |
| OUTPATIENT RIGHT HEART CATH | 5 | 5 | 100% |
| OUTPATIENT SURGERIES BILLED WITH UNITS GREATER THAN 1 | 5 | 4 | 80% |
| OUTPATIENT SNF CONSOLIDATED BILLING | 5 | 3 | 60% |
| OUTPATIENT CLAIMS WITH BYPASS MODIFIER 59, XE, XS OR XU | 16 | 8 | 50% |
| OUTPATIENT CLAIMS PAID IN EXCESS OF $25,000 | 14 | 0 | 0% |
| OUTPATIENT TOTALS | 35 | 11 | 31% |
| COMBINED TOTALS | 335 | 114 | 34% |
The complete OIG audit reports can be accessed here: