NOTE: All in-article links open in a new tab.

OIG Hospital Compliance Reviews Top Twelve Risk Issues

Published on 

Tuesday, December 3, 2013

 | FAQ 
 | OIG 

The Office of Inspector General (OIG) began reporting Hospital Medicare Compliance Reviews in March of 2011. Almost three years into these reviews the OIG has posted results from seventy-nine (79) hospitals. To date, hospitals in thirty states have been subject to a Compliance Review, three hospitals have had the amount to be returned to the Contractor extrapolated and only one hospital “generally complied with Medicare requirements for billing.”

In keeping with the holiday spirit instead of “remembering our favorite things,” here are the Twelve (12) top Inpatient (IP) and Outpatient (OP) “at risk issues for noncompliance” that the OIG has been looking at during their reviews:

  • IP Short Stays,
  • OP & IP claims paid in excess of charges,
  • OP & IP manufacturer credits for replaced medical devices,
  • IP claims billed with high severity level DRG codes,
  • OP claims billed with Modifier 59,
  • IP same-day discharges and readmissions,
  • IP transfers,
  • IP claims with payments greater than $150,000,
  • OP claims paid in excess of $25,000,
  • OP claims billed with E&M services,
  • IP hospital-acquired conditions and POA reporting, and
  • IP Psychiatric Facility (IPF) ED adjustments.

In the past several weeks we have written several articles about the 2014 IPPS Final Rule, including the Probe and Educate Program that is effective from October 1, 2013 through March 30, 2014. During this time Medicare Administrative Contractors (MACs) will be conducting pre-payment probes for medical necessity of IP stays with a 0 – 1 midnight length of stay. During this time the Recovery Auditors (RA) are not allowed to review claims within this time period. A word of caution, this has been the top issue for OIG Medicare Compliance Reviews and the OIG can and probably will continue to review this risk area as they are not impacted by the Probe and Educate Program.

Article Author: Beth Cobb, RN, BSN, ACM, CCDS
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Protection Assessment Tool.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.