Viewing posts categorised under: Audits

OIG Fraud Recoveries Dropped $1.2B This Year

Compliance, Healthcare, OIG, Payment Rates

The Office of the Inspector General Fraud Recoveries Dropped $1.2 Billion This Year

That might not be a bad thing.

The federal government brought in 30% less in fraud recovering in 2018 than it did the previous year, thanks to far few large settlements. But the could be a net benefit, according to the Centers for Medicare & Medicaid Services (CMS). The office of Inspector General (OIG) recovered $2.9 billion from fraud investigations during fiscal year 2018, according to the semiannual report to Congress released last week. That's  $1.2 billion decline from last year, when the agency pulled in $4.13 billion (Sweeney, 2018) The year prior, the agency hauled in a historic $5.6 billion. But lower recoveries are not indicative of lighter enforcement, according to OIG spokesperson Don White. Fraud recoveries fluctuate from year to year, based primarily on the volume of large settlements. In 2017, for example, the OIG inked a $155 million settlement with EHR vendor eClinicalWorks and Mylan paid $465 million in an EpiPen settlement. The prior year, Tenet Healthcare forked over more than $500 million (Sweeney, 2018). On another note…a little alarming because CMS does budget in a % of recovery dollars to justify their fraud investigation program. Resources Sweeney, E. (2018). OIG fraud recoveries dropped $1.2B this year. That might not be a bad thing. Retrieved from:
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians Click here to read more.
Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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Understanding the HH CAHPS Survey and How it Impacts Your Home Health Agency

CAHPs, Events, Survey Protocols

Understanding the HH CAHPS Survey and How it Impacts Your Home Health Agency

Live Recording from February's Select Connects With Clinicians

Learn the purpose of HH CAHPS survey and how it can be used to enhance accountability and reportability for clinicians, nurses, and field staff.

Understanding the HH CAHPS Survey and How it Impacts Your Home Health Agency


  • Understand the purpose of HH CAHPS
  • Understand conducts HH CAHPS Survey
  • Understand how the HH CAHPS produces comparable data
  • Understand how the HH CAHPS produces public reporting
  • Understand how the HH CAHPS enhances accountability
To watch Understanding the HH CAHPS Survey and How it Impacts Your Home Health Agency live presentation fill out your name and email address

Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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Comprehensive Auditing and Coding Review Services

Audits, Clinical Documentation Improvement

Comprehensive Auditing and Coding Review Services

Have Questions? We Have Answers.


Select Data provides home health and hospice agencies with a comprehensive audit service, including a thorough review of clinical documentation improvement and coding practices, as well as detailed reports, assessing audit risks and potential unrealized reimbursements.

Is your agency accurately billing for all of the services your clinicians are providing your patients? Many agencies are not aware of the cumulative monetary losses due to inadequate documentation and inaccurate coding practices. Failure to comply with proper sequencing can make your agency susceptible to audits. Compliance inaccuracies can leave your agency exposed to potentially threatening coding audits. We perform a comprehensive review of your current coding quality that will bring to light any inconsistencies in your coding practices. Through our review of your documentation and coding practices, we help agencies identify how coding errors are impacting their bottom line. Learn more about our comprehensive Auditing and clinical documentation improvement service today!  

Contact us to receive your Getting Started with Your Coding Review packet and we’ll provide you with everything you need to begin the process of seeing how accurate coding can improve your bottom line and reduce your audit risk.

Let us help!

Let us show you how we can help your business run smoother

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Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians Click here to read more.

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Credit Balance Overpayment Refunds: Auditing and Documenting Best Practices. Starting the New Year Right!

Audits, Clinical Practices, Compliance, Legislation, Payment Updates

Credit Balance Overpayment Refunds: Auditing and Documenting Best Practices. Starting the New Year Right!

Do you have Risk? High risk is not the way you want to start out in the New Year.

Failure to return an overpayment can be a violation of the False Claims Act. CMS expects agencies to have indicators of overpayments in place. Ignorance is not an acceptable excuse. Agencies are to return an overpayment within 60 days of identification or face serious potential consequences. What is an Overpayment? According to the Social Security Act, Section 1128J, any funds that a person/agency receives or retains under Title XVIII or XIX to which the person, after applicable reconciliation, is not entitled, constitutes an overpayment. These can include claims for services after benefits have been exhausted, payment for non- medically necessary services, duplicate payments, and payment of claims that exceeded a reasonable charge. Watch out for Credit balances! These are usually caused by contractual “over adjustments,” misapplication of payments, and overpayments. Your agency should have policies and procedures in place to identify and analyze your current credit balance landscape. Create a report with the current aging balance, account identifiers such as account numbers, list all payors whose funds were credited to the account, list dates of service and all charges coupled with payment dates, names and amounts. Periodically perform an audit of your agency processes to be certain any overpayments in the credit balance landscape are identified. You must consider, if the individuals conducting the audit are qualified to do so, what methodology will be employed to identify the overpayments, and do you have a current process to return the overpayments? Do you have adequate QA and root cause oriented processes? Evaluate the sufficiency and effectiveness of the controls necessary to ensure refund and reporting within the 60 days of identification. Be certain your agency can validate the accuracy of the credit balance reports used for operational management and agency compliance oversight. Monitor on an ongoing basis. Be certain policies and procedures meet current regulation requirements. Make certain resolutions are accurate and be certain the controls are functioning as expected. Be certain to note how each error was found, as required in the 60 day repayment rule. Complete the Corrective Plan of Action and the reason for the refunding of the overpayment. Have the OIG Self Disclosure protocol in place with the description of the methodology used. Under the Final rule providers may use “an applicable claims adjustment, credit balance, self-reported refund or another appropriate process to satisfy the obligation to report and return overpayments.” Remember, lack of compliance with the regulation can result in fines of up to $11,000 for EACH improper payment received and not returned going back 6 years. For more information regarding Revenue Cycle Management and billing/collection for your agency, contact Carla Putnam, VP, RCM, Select Data 1.800.332.0555
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians webinar on December 14, 2016. Click here to read more. Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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Hospice and Medicare Part D: Get the Facts

Hospice, OIG

Hospice and Medicare Part D: Get the Facts

Hospice and Medicare Part D: Get the Facts. New CMS Guidance.

Medicare Part D is a Federal program designed to subsidize the costs of prescription drugs and prescription drug insurance premiums for Medicare beneficiaries.  In 2014 Medicare paid over 77 billion dollars in Part D benefits serving more than 37 million beneficiaries.  Part D administration depends on extensive coordination and information sharing between the Federal and State agencies, healthcare providers, drug plan sponsors, contractors and third-party payers. Hospice programs are required to provide individuals receiving Hospice care with drugs and biologicals related to the palliation and management of the terminal illness defined in the Hospice plan of care.  Medicare pays the Hospice agency for each day in which the patient is receiving hospice care, regardless of the amount of care received on a given day.    Hospice is a Medicare Part A benefit and drugs provided by the hospice are covered under the Medicare payment to the hospice program and not covered under Part D. Prescription drugs may be covered under the Part D benefit for the patient receiving Hospice care if the drug is unrelated to the terminal prognosis of the individual.   In 2012 the Office of the Inspector General (OIG) identified situations in which Medicare was paying twice for prescription drugs for hospice beneficiaries, and those beneficiaries may be paying unnecessary copayments for prescription drugs.  The report indicated that most hospice beneficiaries generally experience common symptoms during the end of life regardless of the terminal diagnosis.  These symptoms include pain, nausea, constipation and anxiety.  The OIG worked with the National Hospice and Palliative Care Organization (NHPCO) to identify 4 common categories of prescription drugs that are typically used to treat these symptoms:  antinauseants, laxatives, analgesics, and antianxiety drugs.  These categories of drugs should be covered under the Hospice benefit; however, some instances occur in which 1 or more of these drug categories may be unrelated to the terminal diagnosis of the beneficiary.  In these situations the Part D benefit is responsible for coverage of the drug and the patient assumes any copayment required. It is beneficial for the provider to understand the steps involved from the Medicare Part D plan sponsor in the coverage or rejection of the claim.
  1. Once the plan sponsor receives a pharmacy claim, for the beneficiary who has elected Hospice and the drug falls into the 4 common categories, the claim may be rejected using the National Council for Prescription Drug Programs (NCPDP)-approved reject coding.
Code Description
A3 This product may be covered under Hospice-Medicare A
75 Prior Authorization Required
569 Provide Notice:  Medicare Prescription Drug Coverage and Your Rights
2. Plan sponsors are required to provide a point of sale message that states: “Hospice Provider- Request Prior Authorization for Part D Drug Unrelated to Terminal Illness or Related Conditions” This message should also include the 24 hour pharmacy help desk number to call with questions. 3. The beneficiary, beneficiary’s representative, or prescriber may contact the plan sponsor to request a coverage determination.
  • The sponsor can contact the prescriber to complete the Prior Authorization (PA) form.
  • The prescriber can provide a verbal explanation to the sponsor as to why the drug is unrelated to the terminal illness or related conditions or complete the PA form and submit it to the sponsor by fax or mail.
  • If the prescriber is unaffiliated with the Hospice provider and is unable or unwilling to coordinate with the Hospice provider to provide the statement, the plan sponsor can contact the Hospice Provider for the statement that the drugs are unrelated to the terminal illness or related conditions or complete the PA form.
In some instances the plan sponsor may contact the Hospice provider and receive information that the drug is related to the terminal illness or related condition but it has been determined to be a beneficiary liability.  Once the plan sponsor has received the statement that a drug is unrelated to the terminal illness or related conditions the adjudication process can take no more than 24 hours for expedited requests or 72 hours for standard requests.  (Section 30.2 Chapter 18 Medicare Drug Benefit Manual) Beneficiary liability indicates that the patient is assuming responsibility for the cost of the drug.  Beneficiary liability can occur when the Hospice interdisciplinary group has determined, after discussion with the patient and family, that the existing medication/s may no longer be effective in the intended treatment and/or may be causing negative symptoms in the individual.  The medications would not be covered under the Medicare Hospice benefit as they would not meet the requirements of reasonable and necessary for palliation of pain and/or symptom management.  The patient may choose to have these medications filled through their pharmacy, if this occurs then the medications then become a beneficiary liability for payment and the cost of the medication would not be covered under Medicare Part D.  A patient may also request a drug for his/her terminal illness that is not included in the Hospice formulary and the beneficiary refuses to try a formulary equivalent first; or the drug has been determined by the Hospice provider to be unreasonable or unnecessary for the patient’s palliation of pain and/or symptom management.  The drug then becomes a beneficiary liability and no payment for the drug will be made under the Part D benefit. Hospice providers are encouraged to use the PA form prospectively to prevent the drug claim from rejecting at the point of sale for those drugs that fall into the 4 common categories that are unrelated to the terminal prognosis and the patient is prepared to obtain the drug.  Section II of the PA form is not required, however, as Part D plan sponsors complete retrospective reviews of medications covered under the Part D benefit that fall into the 4 common categories while the patient receives care under the Hospice benefit, the provider would find that incorporating the completion of section II in their practice would mitigate any questions in the future. The information covered in this article represents a fraction of the complexities associated with regulations that govern payment under Medicare benefits.  Select Data is dedicated to assisting your agency in answering these questions to enable you to meet the needs of your patients.  As an expert in the language of CMS, Select Data has over 25 years of preparation to service you.
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians webinar on December 14, 2016. Click here to read more. Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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Pre-Claim Review Demonstration

Legislation, MACs, OASIS, Payment Updates


Pre-Claim Review Demonstration

Effective August 1, 2016, CMS institutes Pre-Claim review in Five States. The demonstration will begin no earlier than August 1, 2016 in Illinois, no earlier than October 1, 2016 in Florida, and no earlier than December 1, 2016 in Texas. The demonstration will begin in Michigan and Massachusetts no earlier than January 1, 2017.


Pre-Claim Review Begins in Five States: August 1st is the First Date, Illinois is the First State

Effective August 1, 2016, Home Health Agencies in five states will begin the three year Medicare pre-claim review demonstration by which an agency will complete the patient assessment, initiate procedures, and establish services then submit a request via fax, mail, or electronic submission of medical documentation to the respective MAC for approval prior to the submission of the final claim. The MAC is expected to provisionally approve or disapprove the services within 10 business days. If the MAC denies the payment, the agency can resubmit a new request

What is the Difference between Pre-Claim and Prior Authorization?

Per CMS, with a Pre-Claim review, services have already begun and the request is submitted after assessments and services have been completed or begun. Prior Authorization requires a request prior to services being initiated. CMS states this new requirement is not creating new documentation requirements. The agencies are to submit the same information they currently submit for payment, but do it earlier in the process.

What States are Included in the Demonstration?

The demonstration will begin no earlier than August 1, 2016 in Illinois, no earlier than October 1, 2016 in Florida, and no earlier than December 1, 2016 in Texas. The demonstration will begin in Michigan and Massachusetts no earlier than January 1, 2017. (Pre-Claim Demonstration for HH FAQ, 6/8/2016)
The demonstration is expected to have minimal effect on beneficiaries per CMS. The Pre-Claim request is submitted after a RAP but before the submission of the final claim. However, some agencies have expressed concern, stating that in an already fragile bottom line market, any further delay of payment could be harmful to the agency’s financial health.
CMS states the five states chosen “show extensive evidence of fraud and abuse in the Medicare home health benefit for treatment performed in these states” (CMS Pre-Claim Demonstration for HH, FAQ, 6/8/2016).

Decision, Documents Needed, and Options

For pre-claim review, the MAC will make the determination using regulation, National Coverage Determination, and Local Coverage Determination requirements. The MACs will be expected to respond within 10 business days for an initial request and 20 business days for a resubmitted request following a denial.
Resubmissions may be sent an unlimited number of times as necessary, but obviously, the agency will want to get the appropriate information submitted up front to minimize payment delays. There will be a tracking number on each decision notice and that number will be used on the claim.
CMS states that, generally those claims that had the provisional review will not have additional review. However, note that Z-PICs conduct targeted prepayment and post payment review which will continue and CERTS review a stratified random sample of claims annually to identify improper payments. That CERT sample may include the pre-claim reviewed items also.
If an agency would be denied payment and after resubmission still receives denial, they could follow the appeal process. If an agency submits a claim without a pre-claim review, per CMS, if that claim is deemed payable, it will be paid at a 25% reduction of the full claim benefit. Obviously, an agency would have serious financial if that became the agency process.


Centers for Medicare & Medicaid (2016). Pre-Claim Review Demonstration for Home Health Services. Retrieved from:
For Start of Care document reviews that includes OASIS review, H&P, med profile, clinician visit assessment and visit documentation review, as well as F2F comment along with ICD-10 coding, CONTACT SELECT DATA at 1.800.332.0555

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Capturing Estimated Length of Skilled Services on a RECERT: Be Aware of the New Focus


Just having frequency and duration alone may not be considered enough justification for that recertification. You need to understand what is now needed. IS IT A NEW or a CHANGED REGULATION? Some in the industry have been talking recently about a change in regulation regarding home health patient recertifications for skilled care. No, the regulation hasn’t changed, but the focus on 42CFR 424.22(B)(2) regarding recertifications certainly HAS changed.  This has been a recertification requirement for several years. However, the incorporation and focus of the recertification regulation language into the home health policy manual is new. Your agency needs to be aware! On a June CGS teleconference this was a topic of discussion. Q&As were posted. One CGS Q&A was particularly interesting, identifying that an agency cannot estimate length of service, but may provide “a written statement with a blank left for the estimated time as a reminder to the physician to complete and sign.” They may also wish to attach any VO regarding specific estimates from the physician that they have obtained. The frequency and duration of visits by discipline planned does not meet the requirement as “there should be something that more clearly indicates how much longer skilled services are needed.” (Per CGS) THE MPBM The updated Medicare Policy Benefit Manual now states: “The physician must include an estimate of how much longer the skilled services will be required and must certify (attest) that:

  1. The home health services are or were needed because the patient is or was confined to the home as defined in 30.1.
  2. The patient needs or needed skilled nursing services on an intermittent basis (other than solely venipuncture for the purposes of obtaining a blood sample), or physical therapy, or speech language pathology services; or continues to need occupational therapy after the need for skilled nursing care, physical therapy, or speech language pathology services ceased. Where a patient’s sole skilled service need is for skilled oversight of unskilled services (management and evaluation of the care plan as defined in, the physician must include a brief narrative describing the clinical justification of this need as part of the recertification, or as a signed addendum to the recertification;
  3. A plan of care has been established and is periodically reviewed by a physician and
  4. The services are or were furnished while the patient is or was under the care of a physician.” (CMS MBPM, Chapter 7-Home Health Services  Section 30.5.2 Physician Recertification
California Association for Home Health Services (CAHSAH) states that requirements for recertification for home health must include a statement by the certifying physician which indicates a continuing need for services and how much longer those services will be required. CAHSAH further notes that Medicare contractors have instructed agencies that the physician should estimate how much longer services will be needed for the entire spell of the patient illness. So you may see dates exceeding the recertification episode end date.  No matter, a statement for the estimation of services will be required for each recertification period, regardless of how long the physician expects home health to be involved. A SAMPLE STATEMENT CAHSAH and other organizations suggest a certification statement such as: “I certify that in my estimation continued home health services will be required for _______________.  Some experts are suggesting the statement be placed in field 21 of the 485 (but physicians may fail to fill in the blank, some worry). Others suggest placing the statement in field 26 so one signature covers this item specifically, as well as certifying care needed for the overall POC. It is anticipated that physicians will be seeking more information from the HHAs as to exactly what they will be doing for the patients.  Some HH Associations suggest supplying the physician with not only the POC, but include a recertification summary or the 60 day summary from the prior episode flagging the specific skilled services and why the patient still meets homebound status.  Recently, an agency leader in California stated her HHA is putting a statement summarizing the patient’s specific needs on the POC. SUMMARY No matter how your agency handles this new focus, know that having the physician simply signing the POC with visit frequency and duration and stating  the patient is homebound will not be enough. So prepare now. You need that additional statement by the physician in which he/she “must indicate the continuing need for skilled services and estimate how much longer the skilled services will be required.” Either put it on the POC or send an additional VO. It is your choice. The MACs will be looking for it. Don’t have a denial of services for lack of compliance with this new focus of an established regulation. For assistance with your OASIS, Coding and Revenue Cycle Management needs call Select Data at 1.800.332.0555    

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The New RAC: Corporate Compliance Programs in Home Healthcare. NOW is the Time

Audits, RACS

The government is escalating investigations through Recovery Audit Contractors (RACs), Medicare Recovery Contractors (MACs), Medicaid Integrity Contractors (MICs), Zone Program Integrity Contractors (Z-PICs), and now, the very active Health Care Fraud Prevention and Enforcement Action Team (HEAT).  Home Health agencies are at a critical crossroads.  It is essential that agencies take control, review processes, and proactively identify and address vulnerable areas.   The MACs will be looking at current claims filed. The RACs will take a retrospective look at claims back three years. The Affordable Care Act identified monitoring and “minimum” requirements of an effective compliance program expecting programs to take steps to ensure the organization’s compliance and ethics program is followed, including monitoring and audit to detect criminal conduct. .It is also expected that an evaluation of the effectiveness of the compliance program will be completed periodically. If ever audited by a government agency, you want to be able to show your compliance plan and the processes involved with that plan. A REVIEW… The RACs: The RAC auditors have been authorized to recover “improper payments “of preapproved areas of risk.  In the demonstration project, high areas of risk included incorrectly coded records, therapy appropriateness, and medically unnecessary services. The RACS use public information from the Office of Inspector General (OIG) and the General Accounting Office (GAO) to focus improper payment audits. RACs have a demonstration project that recovered over 96% of all audited claims resulting in take-backs of 1.3 billion dollars. Is it any wonder that the home health industry is concerned about their new focus? RACs are contingency based, so, they are motivated to seek out variances.  They can audit 1% of the average monthly Medicare episodes of care (maximum 200) every 45 days per NPI. There is a RAC designated only for home health, hospice, and DME. The HSS and the U.S. Department of Justice have teamed up to create the new Health Care Fraud Prevention and Enforcement Action Team (HEAT) to investigate and work to eliminate fraud in healthcare. They are using technology as a key tool for their mission. Their initial focus was directed toward Durable Medical Equipment, as well as services paid for by Medicare Part C (Medicare Advantage) and Part D (Prescription Drug Programs). They have since been very active in home health care. To have reassurance that one could withstand a RAC/MAC/MIC etc audit, agencies should be reviewing samples of past claims, scrutinizing present processes, educating personnel, and updating the Corporate Compliance Plan. The OIG believes that effective compliance programs should include the following components, which are based on the seven steps of the Federal Sentencing Guidelines.   OIG Expected Components of a Compliance Plan:

  1.             Compliance Policies and Procedures to include written standards of
  1.             Designation of a Compliance Officer and Compliance Committee
  2.             Ongoing Education and Training
  3.             Effective lines of communication; Process for Reporting Concerns,
such as a hotline
  1.             Enforcement of Standards
  2.             Development of an Auditing and Monitoring System
  3.             Corrective Action Process for Correcting Compliance Problems
The Corporate Compliance Plan should represent the enterprise-wide initiative designed to detect and prevent problems of noncompliance and include:
  1. An Introduction and Purpose complete with expectations.
  1.             Directives
    •             Key Personnel
    •             Standards
    •             Reporting
    •             Confidentiality
    •             Response and Corrective Action
    •             Enforcement and Discipline
  1. Standardized Conduct
    •             Standards for Business Conduct
    •             Code of Conduct
  1. Code of Ethics
  2. Employee Open Communication :
    •             Agreement with the National Hotline Service
    •            Tracking all calls including interventions
Effective programs have strong internal controls to promote adherence to applicable federal and state laws. They will also include internal auditing components of agency processes, services, and products with feedback mechanisms. There is a well defined agency code of conduct with a compliant culture and frequent employee training.  An infrastructure includes a Corporate Compliance Officer who, in addition to other duties, will monitor industry areas audit focus. The agency can then explore their vulnerabilities. The OIG Top Medicare PPS Compliance Issues include:
  • Reporting additional visits not made in order to exceed LUPA and therapy thresholds
  • Providing additional visits to avoid LUPA and therapy thresholds
  • Upcoding and downcoding on the OASIS
  • Duplicate bills and timeliness
  • Returning credit balances promptly
  • Routine waivers of copays
  • Billing for services without physician orders
The RAC Demonstration Project issues include:
  • Incorrectly coded patient records 35%
  • Lack of Medical Necessity found in the patient records 40%
  • Insufficient documentation in the patient record 10%
Besides the above areas that might bring about adverse financial impact and raise questions regarding potential fraud and violations of the False Claims Act (False Claims Act 31 U.S.C. 3730), home health Corporate Compliance Officers must  also be aware of HIPAA compliance, Patient Freedom of Choice 1802, Conditions of  Participation (CoP) and licensure violations as well as monitoring referrals to prevent referral kickback violations (Stark II, Phase III, SSA 1877) and Civil Monetary Penalties, SSA 1128(a)(5). Home health agency compliance officers should expect to remain on the frontline of risk assessment and enforcement of health care regulations. The RACs, MICs, MACs, Z-PICs, and HEAT are only just beginning. For additional information and what to expect from CMS in the future, look at the Medicare Managed Care Manual Chapter 21- Compliance Program Guidelines. The healthcare map is changing. ACOs are growing. They expect compliance and quality care with positive outcomes as a given. They may ask what completes your agency compliance dashboard. Do you have a compliance dashboard? How often is it produced? Metrics should include recruitment gauges, background screenings, Education/training metrics, numbers of coding and billing audits, as well as HIPAA breaches. It may be time to look at outside experts for areas of risk, such as Coding and Billing, especially in light of the looming ICD-10 CM. A positive by-product of an organization that effectively implements a Corporate Compliance Plan is the emergence of a renewed vision of the future. In this age of government audits, a forward thinking organization will create or update their program for all of the right reasons. However, corporations will soon realize that they can leverage their compliance programs as public relations tools, which not only affirm their role, as solid community citizens, but, also as business associates who share commitment to integrity and ethics.   Susan Carmichael MS, RN, CHCQM, COS-C, ICM Fellow of the American Institute for Healthcare Quality Executive Vice President Chief Compliance Officer Select Data 4155 E. La Palma Ave Suite 250 Anaheim, CA 92807 714.524.2500 x235 714.577.1015 Fax 949.584.6296 Cell

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The OIG Work Plan and Your Agency


The Office of the Inspector General releases an annual Work Plan. This year’s plan holds much for all levels of health care. Be certain you review the plan when updating your Corporate Compliance Plan. The Work Plan essentially reflects projects originating and approved within the Office of Audit Services (OAS) responsible for billing/ financial audit and projects approved within the Office of Evaluations and Inspections (OEI). Keep in mind that not all carry-over projects are listed in new annual Work Plans. Acute Care There are 23 projects listed, 12 are new projects. These projects include an analysis of executive salaries, reviewing billing variances among hospitals and implementation of the Two Midnight Rule. Comparison of provider-based and free-standing clinics will occur as well as a nationwide review of cardiac catheterization and heart biopsies. Physicians Physicians are targeted with reviews in ambulatory surgical centers and end- stage renal centers. CMS will be reviewing qualifications of mental health care providers. Nursing Homes The OIG will continue strong review of nursing homes with high rates  of re-hospitalization and also questionable billing trends. They will also be auditing for national background checks of long-term care employees. DME Equipment The OIG will be comparing amounts paid by payors in regards to fee schedule methodologies targeting commode chairs, folding walkers, and TENs devices. They will also be evaluating F2F physician –patient exams for power mobility devices. Home Health Services The OIG will continue its focus on home health agencies and their conducting of criminal background checks on employees. Since a prior OIG results report found that 1 in 4 home health agencies had questionable billing practices, the OIG will continue to hone in on billing. “Documentation to support claims” is a key area of scrutiny. Hospice Hospices have been heavily reviewed and will have continued review as to use of general inpatient care and the appropriateness of these claims. Scrutinizing levels of care, length of stay, and terminal illnesses of hospice patients in ALFs is required under the Affordable Care Act which mandates reform of the hospice payment methodology. Summary Every area of health care is under review and the government has added resources to improve success of the Work Plan. Home health agencies should review clinical documentation. Most agencies believe they have clinicians who are inconsistent in documentation quality. Some agencies are unaware of specific documentation for required for coding. Now is the time to consider third party coding services to assist in that endeavor or at least consider periodic audits. Select Data provides both

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