Corporate Compliance

Auditing against the OIG's Compliance Program Guidance for Hospitals

Healthcare Auditing Weekly, December 6, 2005

Today, we'll continue our discussion of auditing against the OIG Compliance Program Guidance for Hospitals with instructions for reviewing the claim development and submission process. This is a lengthy aspect of auditing against the Program Guidance, so we will break our discussion of this portion into four parts over four weeks.

To begin this portion of the audit, ask the following questions about your facility's policies for claim development and submission:

  • Do policies require proper and timely documentation for all physician and other professional services prior to billing?

  • Do policies require the organization to submit claims only when appropriate documentation supports the claims and only when such documentation is maintained and available for audit and review?

  • Do policies indicate that the organization should base the diagnosis and procedures reported on the claim in the medical record and other documentation?

  • Do policies indicate that the documentation necessary for accurate code assignment should be available to coding staff?

  • Do policies provide that the compensation for billing department coders and billing consultants should not provide any financial incentive to improperly code claims?

      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.

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