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The OIG Has Released New Hospital Compliance Audit Reports

The OIG Has Released New Hospital Compliance Audit Reports December 11, 2019

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:

https://oig.hhs.gov/oas/reports/region4/41808064.pdf
https://oig.hhs.gov/oas/reports/region4/41808063.pdf
https://oig.hhs.gov/oas/reports/region5/51800040.pdf

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