OIG Hospital Compliance Audit – High Risk Areas

The OIG recently published a hospital compliance audit report that addressed several high risk areas already identified by the OIG and CMS in prior audit reports and in their most recent Semi Annual Report to Congress. 

This particular OIG audit is part of a larger series of ongoing audits.  The OIG is using computer matching, data mining, and data analysis techniques to identify hospital claims that are at risk for noncompliance with Medicare billing requirements. It is with those methods the OIG targeted this hospital. The audit covered CYs 2016 and 2017.

Out of the 100 sampled claims, 37 did not comply with Medicare billing requirement totally $830,291 in combined overpayments.  The overpayment estimate amount for the audit period is over $11 million dollars. 

The findings in this audit included:

  • Incorrectly billed inpatient rehabilitation facility (IRF) claims.  Specifically, the documentation did not support:
    • Patient required active and ongoing therapeutic interventions of multiple therapy disciplines
    • Patient could actively participate/benefit from an intensive rehabilitation therapy program
    • Patient stability at the time of admission to the IRF to be able to actively participate in the intensive rehabilitation program
    • Required need for physician supervision
  • Incorrectly billed inpatient claims that did not meet the criteria for inpatient stays.  Rather the documentation supported an outpatient/observation status was appropriate.
  • Incorrectly billed modifiers, specifically modifier XU-unusual non-overlapping service as part of the modifier 59 subset.  Specifically, the documentation did not support distinct services.

Other risk areas identified by the OIG include:

  • Inpatient claims billed with Comprehensive Error Rate Testing (CERT) high-error rate DRG codes
  • Inpatient claims billed with high-severity-level DRG codes
  • Inpatient mechanical ventilation claims
  • Inpatient short stays
  • Outpatient claims paid in excess of $25,000
  • Outpatient claims paid in excess of charges
  • Outpatient bypass modifier claims
  • Outpatient surgeries billed with units greater than one
  • Outpatient billing for dental services

We recommend conducting internal auditing and monitoring of your hospital coding and billing departments, specifically targeting these high risk areas identified in this report, prior audit reports, their Semi Annual report as well as the Work Plan to validate compliance with the Medicare billing requirements.

You can read the full OIG report here: https://www.oig.hhs.gov/oas/reports/region2/21801025.pdf
You can read the OIG Work Plan here: https://www.oig.hhs.gov/reports-and-publications/workplan/index.asp
You can read the OIG Semi Annual Report here: https://oig.hhs.gov/reports-and-publications/semiannual/index.asp
HBE’s team of coding and compliance experts is available to assist you with external reviews of your documentation, coding and reimbursement as well as providing customized education and training for your staff.  We are also available to provide assistance with conducting risk assessments, internal investigations and policy and procedure development.  

DISCLAIMER:  This newsletter contains only summary information and highlights; it should be read in conjunction with the full article or document provided as a link.  Any advice or recommendations are general and specific questions should be directed to professional counsel

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