Corporate Compliance

Auditing against the OIG's Compliance Program Guidance for Hospitals

Healthcare Auditing Weekly, January 3, 2006

Today, we'll continue instructions for auditing against the OIG's Compliance Program Guidance for Hospitals. Last week, we concluded instructions for reviewing the claim development and submission process. This week, we'll discuss strategies for auditing procedures related to medical necessity. To complete this process, ask the following questions:

  • Do policies and procedures require the hospital to submit claims only for services that the hospital believes are medically necessary and are ordered by a physician?

  • Does the hospital educate healthcare professionals on Medicare's medical-necessity standards?

  • Does the hospital have a clear and comprehensive summary of the medical-necessity definitions and rules of government and private plans? Has it been distributed appropriately?

  • Does the hospital have a process in place for physicians to access FI local medical review policies?

    Next week, we'll discuss strategies for auditing policies and procedures related to anti-kickback and self-referral concerns.

      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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