The Power of a Quality Review: Your Best Defense Against OIG Audits

The following is a guest article by Rebecca Darnall, Risk Adjustment Leader at Episource.
You don’t have to be a fortune teller to see the future of auditing at the Office of Inspector General (or OIG). It has given every indication that it intends to investigate fraud, waste, and abuse more robustly in the foreseeable future. To that end, the agency doubled its budget for audits in 2022. The clear message is to expect — and prepare for — more audits.
These actions are more than just saber-rattling. The risk of audits is a legitimate threat to all payer organizations. As proof, several health plans have been making headlines for coding errors and other issues that surfaced during audits:

In just the third quarter of 2022, at least four audits have specifically targeted Medicare Advantage plans.
The Justice Department has joined the fraud case against one large national insurer.
The New York Times claimed eight of the 10 largest Medicare Advantage insurers had padded their bills.

You don’t want to be the next health plan to make headlines for all the wrong reasons. The best way to prevent a potentially damaging OIG audit is to audit yourself proactively. Realize that, in this era of increased scrutiny, the industry gold standard of 95% coding accuracy might not be good enough anymore.
When you dig into the audits and lawsuits mentioned above, trends emerge. In most of these situations, the problems boiled down to one central issue: ineffective policies and procedure...

Source: EMR and HIPAA - February 2, 2023 Category: Information Technology Authors: Guest Author Tags: Administration Healthcare IT Regulations Revenue Cycle Management Audits Centers for Medicare & Medicaid Services CMS Coding Errors Demographic Error Encounter Error Episource Health Plans Insurance Missed Condition Mock RADV A Source Type: blogs