Corporate Compliance

Prioritize OPPS audits

Healthcare Auditing Weekly, January 6, 2004

Use a "finders and fixers" plan to review and correct your biggest compliance issues. People inside of the organization are the best at knowing how systems work and what steps are required to fix incorrect claims, but they may not know what to look for or how to find it. That is where outside help can help you find your compliance vulnerabilities. By fixing the issues yourself, your staff learns what the problems are, how they were uncovered, and how they can be avoided in the future.

The list below is a starting point for some of the key areas to audit internally:

  • Focus on all areas of risk as identified in the OIG work plan
  • Audit the UB-92 and chargemaster for new codes, old codes, and deleted codes
  • Review your denial management process
  • Review billing of pass-through items, especially from 2001 and 2002
  • Review units of service reporting especially for drugs
  • Review the charge capture process in the ED, as well as other departments including the cardiac cath lab, interventional radiology, and in your clinics
  • Check modifier usage, especially -25, -52, 59, 73, and 74
  • Check evaluation and management guidelines created and distribution of code levels
  • Investigate use of observation, including all criteria being met before billing
  • Check charges reported in high-volume APCs, APCs generating a high volume of outlier payments, or both
  • Review highest outpatient code editor edits

    For more on outpatient prospective payment system compliance, order the book "Compliance Troubleshooter: Tackling the Top 10 Compliance Challenges." This book features information on The False Claims Act, outlier payments, quality of care, economic and traditional economic credentialing criteria, EMTALA, nonphysician practitioners, billing and documentation, outpatient prospective payment system, Stark, and inpatient compliance issues. Click here for more information or to order.

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