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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Compliance Program Development Required by 2013


Have you started developing your compliance program yet?  Do you have a compliance program that is incomplete or not as active as it should be?

The Health Care Reform Act and the Patient Protection and Affordable Care Act require a compliance program be implemented by 2013 for all health care providers and dental providers that bill Medicare and Medicaid or any federal and state funded programs. The OIG (Office of Inspector General) has had suggested compliance program guidance for several years for hospital, physicians, DME and home health. I would recommend health care providers start planning by using these OIG guidelines because it will take at least 9 months to have a program implemented completely. A compliance program will also help your business run more efficiently if the program is managed correctly.
Compliance programs focuses business operations & management, contracts, relationships, billing, and the laws associated with each. Two key components to ensure success for the program is executive support and employee participation.   A compliance program  is more than policies.
The elements of a compliance program include:
1. Compliance Officer, which may hold several positions in smaller agencies.
2. Compliance Committee, best to have managers or supervisors from various departments to be a solid advisory committee.
3. Standard of Conduct covers various topics from Stark Law, Antikickback statute, Company funds, Investigations & legal matters, billing expectations, complaint reporting, and much more.
4. Policies and Procedures expand some sections of the standards of conduct such as the billing section.
5. Training of at least 5 hours per year, in addition to the training for privacy and security annually.
6. Auditing and Monitoring help ensure the risk areas for the company and identified by the OIG stay within the regulations and coverage criteria, prevents fraud and abuse or at least early detection, and training to prevent the repeat of erroneous actions.
7. Hotline for reporting,even if it is a local phone number for small companies with 1 to 2 locations. Complaint reporting should not be limited to a hotline.  Complaints should be allowed by email, mail, and fax as well. You need a hotline poster, but it does not have to be elaborate or expensive.
If you can you help with your compliance program, we have extensive experience in health care compliance program development and management.

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.

Compliance Programs Required 3/25/2013


Well, we thought with Health Care Reform Act of 2010 that providers had 3 years from the signature date to have a plan implemented. With the final provisions of the Patient Protection Affordable Care Act, you have until 3/25/2013…less than 2 months to have a compliance plan in place.   They make reference to the 7 element compliance program currently recommended as a basis for the program structure. The final rule has language that reads as though they will withhold payment to providers that do not have compliance program in place.  Don’t worry, we can help you with a simple compliance program that is affordable.

A few other items that impact business decisions. This takes effect 3/25/2011 for all new providers and March 2012 for all existing providers.

1.  Moratorium on Medicare, Medicaid & CHIP provider numbers based on products and number of suppliers in the area.  This may not be as easy anymore.

2.  Application fees of $500 each for all providers excluding physicians and nurse practitioners and their group practices. If a provider applied for Medicare and Medicaid then only one fee will be required, but proof of Medicare application may be required.

3.  New screening and Fingerprinting requirements. Note Florida has had fingerprinting in place for over 8 years. You have to have a criminal record and there are many fraudulent providers that currently do not have a record. This applies to owners of 5% or more of the company, directors and officers.

4.  Unscheduled & unannounced visits to check up on suppliers.

5.  Re-enrollment for Medicare every 3 years and Medicaid annually and fees will apply plus inflation rate for CPI.

6.  New state licensing requirements to come from this also.

If you do not have a compliance program or haven’t taken your seriously, it is a requirement that could result in suspended payments.

With proven experience in the health care compliance, We can help you with a compliance program policies and procedures as well as teach you to manage your program or help you manage the program to ensure you pass the government inspection to ensure effect within 3 years of implementation. They can request random audits for privacy and security to ensure you are meeting requirements and now they have added billing compliance.

We can also help you with provider applications to ensure they are done right the first time.

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.

Scope of Services for www.medicalauditingsolutions.com


We thought it would be helpful if in our first blog we explained our SCOPE OF SERVICES for the Medical Auditing Solutions LLC.  We work with all types of health care providers including Durable Medical Equipment, Respiratory Med Pharmacy, Sleep Labs, Home Health Agencies, Small Physician Practices and Hospital Systems.  Our clients revenues vary tremendously from $2M-well over $100M annually.  Our focus is to help you manage your business by giving your problem solving direction although we can perform the hands on work as well.

  • Compliance/HIPAA Audits
    • Review patient charts to ensure compliance with billing and regulatory requirements and exit with management to discuss any areas of weakness with a written report to follow
    • All improve collections and efficiency
  • Compliance Program Development and Training
    • We can review your existing program and provide updates
  • Due Diligence Audits
    • Review patient charts as above and provide general feedback on branch, personnel, location, etc.
    • See Compliance Audits
  • Investigations including audits, interviews, etc. in coordination with your attorney, if applicable
  • Medical Accounts Receivable Analysis for Improved Collections
    • Review a sample of writes for accuracy and potential recovery
  • Medical Accounts Receivable Aging claim filings and staff education
  • Regulatory Affairs Filings To Do Business (NPI, licensing, permits, DBA’s, Certificates of Authority, provider/supplier applications)
    • Handle all filings, follow-up and renewals
  • Assess Medical staff knowledge and positions
  • Assess overall location
  • Assist with Health Care Accreditation, HR, and Operations
  • Work with the business to improve overall efficiency and profits
  • Practice Management and Quality of Care Auditing
    • Other healthcare consulting as needed see website

Monthly Availability via a retainer at competitive rates customized for your needs and the time period needed.