Corporate Compliance

Auditing against the OIG's Compliance Program Guidance for Hospitals

Healthcare Auditing Weekly, December 20, 2005

Auditing against the OIG's Compliance Program Guidance for Hospitals

This week we'll continue our four-part discussion of reviewing the claim development and submission process when auditing against the Compliance Program Guidance for Hospitals. This week, we'll discuss processes for submission of claims for laboratory services.

First, identify whether hospital policies take reasonable steps to ensure that all claims paid for clinical and diagnostic laboratory-testing services are accurate and correctly identify the services ordered by the physician and performed by the laboratory. Identify whether the hospital has policies and procedures to ensure that

  • the hospital bills for laboratory services only after they are performed

  • the hospital bills only for medically necessary services

  • the hospital bills only for those tests actually ordered by a physician and provided by the hospital laboratory

  • the common procedural terminology or Healthcare Common Procedure Coding System code used by the billing staff accurately describes the services ordered by the physician and performed by the hospital laboratory

  • the coding staff only submit diagnostic information obtained from qualified personnel

  • the coding staff contact the appropriate personnel to obtain diagnostic information in the event that the individual who ordered the test has failed to provide this information

  • diagnostic information is obtained from the following with respect to all claims submitted on behalf of teaching physicians:

    -The hospital only bills for services actually provided

    -Every physician who provides or supervises the provision of services to a patient is responsible for the correct documentation of the services rendered

    -The appropriate documentation is placed in the patient record and signed by the physician who provided or supervised the provision of services to the patient

    -Every physician is responsible for ensuring that patient medical records document applicable key components of evaluation and management services provided, as well as adequately reflect the portion of the service performed by the physician

    -Every physician documents his or her presence during the key portion of any service or procedure for which payment is sought

    Next week, we'll discuss processes for reviewing cost reports.

      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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