By: Barbara Aubry
On November 16, 2011 CMS announced new demonstration projects to help curb fraud and abuse. You may recall that in 2010 President Obama announced the goal of reducing overall payment errors by $50 billion, cutting the fee-for-service error rate by 50% and recovering $2 billion in improper Medicare and Medicaid payments.
As of January 1, 2012 CMS intends to begin demonstration projects to safeguard the Medicare trust fund by increasing the Recovery Audit Prepayment Reviews, prior authorization for specific DME and a continued focus on Part A to Part B rebilling.
For the OIG, their 2012 Work Plan includes ramped up compliance reviews and audits of between eight and 24 identified risk areas. They intend to focus on a pool of 3.600 acute care hospitals and will choose specific facilities to audit based on various criteria. As reported by “Report On Medicare Compliance” the OIG intends to target short stays, claims paid in excess of charges and manufacturer’s credits for DME under warranty. For more, see the OIG 2012 Work Plan.
My Take:
The threat of Federal audits continues to grow and the auditors are going to be looking closely at your facility’s past performance to determine if you fall within their cross hairs in 2012. They will consider your prior performance on audits – and whether you continue to have problems. They are also looking at your billing volumes compared to your competitors using your Program for Evaluating Payment Patterns Electronic Report (PEPPER). If you are an outlier they are more likely to knock on your door. Both continue their review on the use of certain modifiers. According to the Work Plan, OIG is beginning a new focus on your facility’s compliance program to determine whether it meets expectations under the Health Care Reform Act. In this ramped-up environment I would not be skimping on compliance efforts. More than ever before focus should be on supporting your HIM coders and auditors by providing the tools that will help them do their jobs more accurately – not only faster. Use of coding and auditing tools can become the foundation of your compliance program. The idea of using EHRs that automatically ‘code’ records and bypass the need for human coding review makes me nervous. If you are considering this route, it should not obviate the need for coding oversight and audit to verify the accuracy of your system. OIG is aware that EHRs may auto populate data which can result in documentation errors. I would not want to be the CFO or compliance officer facing the OIG and having to admit that my facility relies solely on the perceived accuracy of an EHR.
