OIG Work Plan 2012


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 have a Healthcare Compliance Program?

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.

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RAC and ZPIC Audits: How to have a Successful Payer Audit?


In the last twelve months, there has been more money than ever before put into fighting fraud and abuse.  Contractors are requesting more charts than ever before to review for fraud and abuse.  How do you have a successful payer audit?  The simple answer is provide the documents requested, but there is more to it.

First, Make a checklist for each chart.  Pull each chart and copy all records requested.  The request period may not include the delivery or start date and copies of initial qualifying test results and/or chart notes, include them if it is pertinent to the determination of ongoing medical necessity for example rentals of equipment.  If you did not obtain the test results or physician chart notes at the time of the start of care, request them now because the physician is not penalized if he does not respond.  Physician failure to respond to a request is an error and results in “overpayment/error” paid by the provider.  It is in your best interest to gather and submit each patient record in an organized manner.  This needs to be top priority because you have limited time frame to produce and failure to respond timely results in overpayment calculations!

Have you seen or heard the “error rates” being published?  The way it sounds, ever provider will have an audit with an error rate, it is just a matter of time.  A error rate published March 1, 2010, by Noridian was over 102 files with 86% error rate.  This is a small sample to create a crisis over.

I would recommend you have an independent third party, whether consultant or your health care attorney,  review the records before you send them off.  You can typically be granted one extension.  Do not wait until the last minute to start this process.  If you have a large number, have someone review a sample then expand based on the determined error rate.

If more than 20-30 charts are requested, I would notify outside counsel.  I am receiving new clients weekly with 200, 300, 400 or more charts being requested.  To produce duplicate copies of these records and obtain physician records in 14-21 days may be difficult and still run your business.

If you haven’t received an audit to this point, be prepared for when it happens.  Any overpayment determination in a payer audit requires payment arrangements prior to the appeal process being completed.  Be proactive, have an audit of your business to be prepared for when that day comes.

Angela Miller of Medical Auditing Solutions LLC has been in health care compliance, 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.  Ms. Miller has extensive experience with Medicare and Payer audits.  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.