I participated in a call on Thursday January 19, 2012, on the OIG Work Plan for 2012. Please reference the link for the full OIG Work Plan spelled out by provider type. Many items on the Work Plan never change but there were a few points I felt important to draw your attention to for risk management purposes. Here are a few notes I made because I think the audit risk is high since the result can be subjective:
1. Outpatient Observation Billing
2. Critical Access Hospitals:
A. Distance to nearest, non-critical access hospital
B. Herceptin and other Chemo Drug quantity
3. Hospice because 82% of patients do not meet criteria to be admitted to hospice.
4. Incident to Services by non-qualified personnel. Even Blue Cross and Blue Shield is recouping and extrapolating on commercial claims for mid-level practitioner billing. Make sure modifier is used when appropriate and the mid-level meets the licensing requirements to provide the services billed.
5. Off Label Prescriptions. Physicians ordering a drug that is approved for Diagnosis A but the drug is used for diagnosis B.
6. Home Health-but not specific because they are going to review 2010 billing before they decide.
7. Dialysis and ESRD Drug costs. What is the drug cost to the provider versus the reimbursement.
8. Contracts providers have with other providers/facilities. Make sure you have a health care attorney to review the contract before executing because the health care attorneys are familiar with the Stark and Anti-Kickback provisions which typically the corporate business attorney does not have to consider.
9. Checking employees, vendors, and providers against Sanction Databases MONTHLY. You may find the federal links on my website. The states have their own links.
10. NY Medicaid reduced the annual revenues to $500K in Medicaid/Medicaid HMO/Managed Care Organizations (MCO) funds for compliance program requirement.
11. Compliance Program Requirement under Federal Deficit Reduction Act that required all healthcare providers to have a compliance program in place by 2007 if their annual collected revenue of State reimbursement was $5M or more. This would include Medicaid and respective Medicaid HMO or MCO.
12. As of 2013 a healthcare compliance program is required for all providers billing Federal or State plans no matter what the annual billing revenue may be. This would include dental practices because they bill Medicaid!
13. Overpayments must be disclosed and refunded within 60 days of identification that it is an overpayment. Failure to refund this money can result in “False Claims” charges and penalties. Ensure you have someone that is accountable for working your credit balance reports monthly. Keep documentation of these reviews and refunds issued as a result in a manner that can easily be explained and found.
The OIG Work Plan can be used to determine risk analysis, structure audit plans, and determine growth opportunities.
Do you review the OIG Work Plan Annually?
What else do you review to determine your audit plan?
We can help you analyze the status of your healthcare compliance program and ensure you have focused on the correct risks for your business model. We are the compliance expert with a vast history and a cost effective way to ensure your compliance program is operating and managing your risk.
Angela Miller of Medical Auditing Solutions LLC has been in health care compliance, auditing, billing, collections and HIPAA for over 18 years. Ms. Miller has made it the focus of the business to help providers run their businesses efficiently, collect money, and maintain compliance with federal and state regulations and coverage criteria through compliance program development, management and training. Ms. Miller is very experienced with Medicare & Payer audits. Ms. Miller ran a very successful compliance program for over 5 years for the largest private held HME/Pharmacy provider in the US at the time. Ms. Miller also works as a contract compliance officer to provide an avenue to compliance training to staff, implementation of policies, as well as handling anything that affects cash flow from the initial intake to back-end collections. You can visit our website at Medical Auditing Solutions LLC.