Corporate Compliance

Auditing against the OIG's Compliance Program Guidance for Hospitals

Healthcare Auditing Weekly, November 29, 2005

This week, we will continue our discussion of auditing against the Compliance Program Guidance for Hospitals. Last week we discussed evaluating your facility's written code of conduct. This week, we'll discuss policies for addressing risk areas. When reviewing whether policies adequately address risk areas, review documentation at your facility for the following:

1. Do policies and procedures account for the regulatory exposure for each function or department of the hospital?

2. Do the organization's policies, at a minimum, address the following risk areas:

  • Billing for items and services not actually rendered

  • Medically unnecessary services

  • Upcoding

  • Diagnosis-related group creep

  • Outpatient services rendered in connection with inpatient stays

  • Teaching physicians and resident requirements for teaching hospitals

  • Duplicate billing

  • False cost reports

  • Unbundling

  • Billing for discharge in lieu of transfer

  • Patient freedom of choice

  • Credit balances-failure to refund

  • Hospital incentives that violate the anti-kickback statute or other similar federal or state regulations

  • Joint ventures

  • Financial arrangements between hospitals and hospital-based physicians

  • Stark physician self-referral law

  • Knowing failure to provide covered services or necessary care to members of a health maintenance organization

  • Emergency Medical Treatment and Labor Act provisions (patient dumping)

    Next week, we will discuss reviewing the claim development and submission process.

      The above tip is an excerpt from the book "Hospital Auditing and Monitoring: Sample Programs for Key Risk Areas." Copyright 2004 by HCPro, Inc. This book is a step-by-step, practical manual that offers sample audit programs for the most troublesome areas that a hospital must audit. The binder and CD-ROM are filled with actual audit programs used by auditors and compliance officers in the field. Click here for more information or to order your copy today. 

        • Strategies for Health Care Compliance

      • Strategies for Health Care Compliance

        News and real-life examples to increase the effectiveness of your compliance program. Strategies for Health Care Compliance...

      • Compliance Monitor

        This HTML e-mail newsletter delivers news on Medicare and Medicaid fraud and abuse, as well as recent documents and targets...

      • Medicare Weekly Update

        Each issue of Medicare Weekly Update includes the latest CMS proposed and final rules, CMS manual revisions, and...

      • Medicare Update for Physician Services

        Medicare Update for Physician Services is a free, monthly e-zine that delivers news and information to help physician...

      Most Popular

      Related Articles