• E-mail
• Print
• RSS

Audit yourself by assuming the role of the OIG

HIM Connection, October 12, 2004

Want to receive articles like this one in your inbox? Subscribe to HIM Connection!

Organizations conducting internal audits to determine how they are doing with APCs will be ahead of the curve, as they will have already identified APC weakness areas. By understanding and addressing these areas-through education, training, development of policies and procedures, and monitoring changes by using data-providers can minimize their exposure to noncompliance.

Take corrective action when you discover trouble spots in your processes. Providers can use the Office of the Inspector General (OIG) Work Plan as a guide for the types of things that need to be reviewed internally.

However, consider addional areas not currently identified by the OIG when determining what to audit. Providers should make a list of all the areas where they are having trouble-and then investigate those areas further.

Use a "finders and fixers" plan to review and correct your biggest compliance issues. People inside the organization are the best at knowing how systems work and what steps are required to fix incorrect claims, but they may not know what to look for or how to find it.

Outside help can find your compliance vulnerabilities. By internally fixing problems, your staff learns what problems exist, how they were uncovered, and how to avoid them in the future.

The list below is a starting point for some key areas to audit internally:

• All areas of risk identified by the OIG Work Plan
• Outpatient services, including education and training for coding and billing
• UB-92, and CDM for new codes, old codes, and deleted codes
• Denial management process; are back-end fixes being made
• Pass-through items, especially from 2001 and 2002
• Units of service reporting especially for drugs and determine if rebilling opportunities exist
• Charge capture process in the emergency department, as well as other departments including the cardiac cath lab, interventional radiology, and your clinics
• Modifier usage; especially -25, -52, 59, 73, and 74
• E/M guidelines and distribution of code levels
• Use of observation including all criteria met before billing
• Charges reported in high-volume APCs, APCs generating a high volume of outlier payments, or both.

If your findings indicate you might be on the OIG's problem facility list, it becomes even more important to resubmit adjustment claims, particularly for high volume or high dollar adjustments. If you find compliance problems but don't correct them, not only will you have to pay back money you received improperly, but the OIG might require you to pay additional penalties.

This excerpt is adapted from the Compliance Troubleshooter: Tackling the Top 10 Compliance Challenges.

Want to receive articles like this one in your inbox? Subscribe to HIM Connection!

• E-mail to a Colleague
• Print
• RSS
• Archive