Proactive External Audits and Other Tips for Avoiding OIG Investigation

As an independent agency that has provided objective oversight of the US Department of Health and Human Services (HHS) since 1976, the Office of Inspector General (OIG) leads efforts to combat waste, fraud, and abuse. Among the federal government's civilian agencies, HHS is the largest. As of fiscal year 2022, the OIG has requested a budget of $428.9 million and operates with more than 1,600 employees. The OIG conducts nationwide investigations, inspections, and audits that may result in criminal convictions, civil penalties and settlements, and administrative sanctions against fraudsters.

Over the last several months, OIG has released three investigative reports that are requiring ACOs to refund millions of dollars in payments due to diagnosis codes not being assigned correctly. This is a significant and alarming trend. The major issue with all three investigations boils down to coding from a problem list.

Healthcare providers must be careful about coding directly from the problem list of a chart. The problem list can be documented as “Patient Active Problem List,” which suggests a list of only those conditions in the patient record that affect the patient’s care. However, the problem list has commonly become a list of all diagnoses assigned to the patient whether they are current, chronic, or even affect the patient’s care at all. Coders should not arbitrarily assign codes to these conditions, and clinicians need to manage the list to ensure that it’s complete, current, and accurate. Until this happens, it is essential for coders to continue reviewing the patient record to ensure that diagnoses documented in the problem list meet reporting criteria. This is not just an issue for ACOs either, it is a frequent issue for coders across all coded accounts and specialties.

Does your organization have a compliance audit plan in place?

Ensuring your compliance audit program is active, effective, and healthy is essential. A system for auditing must be implemented to measure the health of your compliance program.

Coding audits are a preventive measure that, regardless of your organization’s size, can safeguard your business. An advantage of conducting an external audit is that vendors can provide highly experienced auditors who bring an outside perspective, new ideas, and solutions to common pain points. When a provider hires an external auditor, the auditor will typically conduct a baseline audit that samples a variety of services to measure the coding compliance of each provider and coder. External audits are commonly performed on a quarterly, biannual, or annual bases depending on the strengths and weaknesses discovered during the baseline audit.

• Make sure billing and coding are compliant and conduct an internal audit at least every quarter.
• Review, update, and assess your internal compliance programs regularly.
• Maintain a current understanding of Medicare and other regulatory policies.
• Register for the OIG email newsletter, which provides updates regarding completed OIG investigations and changes to the OIG Work Plan. Check the OIG website frequently and review new items that are added to the OIG work plan.
• Create robust internal coding, documentation, and medical necessity audit programs. Provide education to revenue cycle management staff, including coding professionals, CDI staff, and physicians, regarding error trends and how to prevent them.
• Perform reaudits as necessary based on your findings and any updates to the OIG Work Plan.