Corporate Compliance

Auditing against the OIG's Compliance Program Guidance for Hospitals

Healthcare Auditing Weekly, December 13, 2005

This week we'll continue our four-part discussion of reviewing the claim development and submission process when auditing against the OIG Compliance Program Guidance for Hospitals. We'll discuss instructions for auditing processes for claims related to outpatient services rendered in connection with an inpatient stay.

First, identify whether the hospital has adopted good-faith efforts to comply with CMS billing rules for outpatient services rendered in connection with an inpatient stay. Take the following measures:

  • Install and maintain computer software that identifies outpatient services that may not be billed separately from an inpatient stay

  • Implement a periodic manual review to determine the appropriateness of billing each outpatient service claim

  • For each inpatient stay, scrutinize the propriety of any potential bills for outpatient services rendered to that patient at the hospital, within the applicable time period

  • Implement and maintain a periodic post-submission random testing process to examine previously submitted claims for accuracy

  • Advise your fiscal intermediary (FI) and any other appropriate government fiscal agents in accordance with current regulations or program instructions about return of overpayments of any incorrectly submitted or paid claims. If the government has already paid the claim, promptly reimburse the FI and the beneficiary for the amount of the claim paid and any applicable deductibles and copayments

    Next week, we'll discuss processes of submitting claims for laboratory services.

      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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