Which Programs Were Put In Place By The Oig To Educate Entities On Proper Claims Submission?

Past Jillian Harrington, MHA, CPC, CPC-I, CCS-P
Each October, the Role of Inspector Full general (OIG) reveals to us in their annual Piece of work Plan what they will be working on with respect to Department of Health and Human Services (DHHS) programs and operations in the upcoming year. This program tin can give yous an idea of what the federal authorities'southward areas of concern are in the public health care sector. You can then use this information to create or update your own compliance piece of work plan.
Last month, we looked at the 2010 OIG Piece of work Programme in regards to dr. practices. This calendar month, we'll look at the items relating to hospitals, and consider how providers can utilize this information to prepare for the upcoming twelvemonth.
New Work Program Items for Hospitals
Infirmary Payments for Nonphysician Outpatient Services Under the Inpatient Prospective Payment System (IPPS)—In the hospital setting, all outpatient diagnostic services and access-related nondiagnostic services provided within iii days prior to an inpatient admission appointment are not paid separately, but payment is considered every bit included in the Medicare Severity Diagnosis-related Group (MS-DRG) payment provided to the hospital for the inpatient access. This is ordinarily known as the three-day window, or somewhat inappropriately, the 72-hour rule. Prior OIG work had shown significant issues in these areas in the past, when it was previously included in the plan. They've included information technology once more this yr, specifically looking at payments fabricated for these services within that iii-solar day time period.
To gear up yourself for this review, await at your current controls, to be certain you lot take appropriate edits in place to preclude billing for these services to the program exterior of MS-DRG payment. If yous do non have automatic controls in place to protect your facility, does your current compliance plan monitor this issue? If not, at present is definitely a great time to expect at the program and include these in reviews for the upcoming yr.
Hospital Admissions with Conditions Coded Nowadays-on-Admission—The rules and regulations regarding hospital acquired conditions (HACs), serious adverse events, and present-on-admission (POA) indicators have non been in identify for very long. It is, however, an area of significant concern to the OIG, equally it's an surface area with potential mistake, fraud, and corruption issues. The OIG will await at claims to decide the number of inpatient admissions for which sure diagnoses are indicated every bit POA and specifically which diagnoses were nigh frequently coded as POA. Under the new rules, a facility receives a lower payment for services if sure weather were acquired in the hospital. This provides a facility incentive to bear witness that a condition was not acquired in the hospital setting, but was present upon the patient's admission to the facility. OIG as well plans to await at transfer activity betwixt facilities, especially those transferring a large number of patients with conditions present upon admission and those receiving transfers of patients with conditions nowadays upon access.
This is a new area to be concerned with in your compliance programs. Hopefully, you are already auditing and monitoring with regard to these types of indicators. If not, it's important to review your POA and HAC coding, equally with whatever new process, there is the potential for errors. It is also a good idea to review your transfer rates, to find if there are any concerning or alarming statistics that might be crimson flags to the OIG.
Infirmary Readmissions—If yous belch a patient from an inpatient admission, and then readmit the patient on the same calendar day for the evaluation or management (E/M) of that same status he or she was initially treated for in your facility, combine the initial and subsequent inpatient stays into a single claim submission for a single MS-DRG payment. The Medicare programme has built edits into their systems to forbid payment of these services, but there are ways to override these edits in the event a patient is discharged and readmitted on the same day for a unlike medical rationale. The OIG plans to review claims for patients discharged and readmitted to the same acute care facility on the same twenty-four hour period, to meet if these edits were overridden properly, or if claims were paid inappropriately.
If you practise non currently have a process in identify in your billing organization to force review of each of these types of claims, it's a good idea to talk over this with your billing director to determine if some kind of automated edit can be put into place. If you exercise take an automatic edit, you may wish to do some auditing of the claims submitted when this edit is overridden to determine whether or not the override was advisable.
Agin Events—There are five items specifically directed at the new Adverse Issue policies under the Medicare program. These reviews are:

• Hospitals: National Incidence Amidst Medicare Beneficiaries
• Hospitals: Methods To Identify Events
• Hospitals: Early Implementation of Medicare's Policy for Infirmary-Acquired Weather condition
• Hospitals: Responses by Medicare Oversight Entities
• Public Disclosure of Adverse Outcome Information

These reviews are all directed at determining if hospitals are appropriately identifying and reporting agin events, and whether or non the current list of Medicare adverse events is appropriate. It is also an indicator of whether their list should be expanded farther to friction match the list published by the National Quality Forum.
As a facility, review your adverse effect reporting process, as it is most probable to be a new, more than expanded process than in the by. Prior to these requirements, dealing with adverse events was the trouble of the medical director and the risk direction/quality assurance divisions. Under these new Medicare guidelines, adverse events span to a much wider group within the facility, including not simply the medical manager and risk/quality divisions, merely also the compliance department, finance, billing, and operations. Be sure at that place is working communication betwixt each of these areas, and tweak those new policies and procedures as necessary to make them work well in this new realm. Consider examining your state Medicaid regulations regarding the aforementioned topic. Each state is implementing its own programme to correlate with these regulations, and some have significantly different lists of adverse events than the Medicare program. Cheque the requirements in your state, and make sure you're in compliance with each gear up of necessary requirements
Note Other Items in the Hospital Work Plan
There are many other important items in the Work Plan this yr that involve hospitals. Some are new and some have been in the plan for a while. They include:

• Part A Hospital Capital Payments
• Provider-Based Status for Inpatient and Outpatient Facilities
• Role A Inpatient Prospective Payment Arrangement Wage Indices
• Payments to Organ Procurement Organizations
• Inpatient Rehabilitation Facility Submission of Patient Assessment Instruments
• Disquisitional Access Hospitals
• Medicare Asymmetric Share Payments
• Duplicate Graduate Medical Instruction Payments
• Interrupted Stays at Impatient Psychiatric Facilities Payments
• Provider Bad Debts
• Medicare Secondary Payer

There are also reviews in other sections of the piece of work program that may be pertinent to your facility, such as the Medicaid programme sections, the Recovery Act Work Plan, or the Public Health program sections. Check out the entire Work Program to know where you stand with the items they'll be reviewing this year. The 2010 OIG Work Program is available for free online at http://oig.hhs.gov/publications/docs/workplan/2010/Work_Plan_FY_2010.pdf.

Jillian Harrington, MHA, CPC, CPC-I, CCS-P, is president/CEO of ComplyCode, a health care compliance consulting and education firm in Upstate New York. She holds a Masters in Health Administration from the Rochester Establish of Applied science (RIT), and is a former member of the AAPC National Advisory Lath (NAB).

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