A mid-year update was released in 2016 by the Office of Inspector General (OIG) to its annual Work Plan. There are various areas which have been reviewed by the feds, which hospitals need to know about in order to avoid drawing negative attention for compliance issues.
While reviewing whether Medicare outlier payments were reconciled and settled properly, the agency also focused specifically on outpatient outlier payments for short-stay claims. The OIG’s looking for probable cost savings for Medicare considering if the hospital outpatient short stays were no longer permitted for outlier payments.
As per OIG, previous reviews has shown that hospital’s expensive charges could add to excessive inpatient outlier payments. The scrutiny, these days, is shifting to outpatient stays. There are several ways in which the hospitals may be affected by these reviews. Outliner payments that are provided to hospitals when their rates exceed some portion of normal Medicare payments, might end up being abolished entirely or decreased. Also, more scrutiny can be expected by the hospitals in regard to the cost they charge for common services – which includes being pressurized to release them in public.
Current Issues:
Most of the discussion areas in the mid-year update, OIG is continuing to review from last fall, which includes:
Inpatient claims for mechanical ventilation – The claims for mechanical ventilation is being looked up by the OIG in order to ensure that hospitals are assigning patients to the appropriate Diagnosis Related Group (DRG) and that the payments for these services are accurate.
The “two-midnight rule” – Although the controversial pay cuts which originally came with this rule has been ditched by the Medicare & Medicaid Services (CMS), the feds are still planning to review as to how it will impact the amount of outpatient and inpatient claims that the hospitals have submitted for reimbursement. The OIG is comparing claims from the year before the rule went into effect, i.e. 2013, and the year following its effective date.
Various other selected inpatient and outpatient billing needs – in order to see whether facilities have received overpayments, the agency has reviewed payments for various services to hospitals. They are keeping a close watch to ensure that hospitals are meeting the billing requirements – and it may need facilities to make paybacks if it ascertains that particular services are routinely overpaid.=
How to Respond
It is essential for hospitals to double-check these areas and ensure that there are no hidden issues which will jeopardize the compliance. It is especially critical with coding and billing, as at present the OIG is looking at claims of every types.
Periodic reviews of internal policies and self-audits of claims might assist the facilities in finding and rectifying any weaknesses before the feds come knocking.
To get more updates, join an online webinar by expert speaker Elin Baklid-Kunz, MBA, CHC, CPC, CPMA, CCS, where she will explain what providers can do, to better prepare and minimize their audit risks as scrutiny intensifies and CMS error rates remain high. Elin will touch upon hot coding issues that every physician’s office needs to know. This information will help you avoid reduced payments, compliance issues, and ensure correct coding and payment the first time, every time.
