Twice a year the Health and Human Services Office of Inspector General (OIG) releases their semiannual report to Congress on healthcare. This report not only helps Congress understand where there are risks, vulnerabilities, and noncompliance but this report also identifies potential improvements that can be made within healthcare itself. For those of us in the Healthcare Revenue Cycle and Health Information Management, we should take the time to review this report and determine if there are “ANY” potential areas that impact your department or healthcare organization.
Catching up on the work of the Office of the Inspector General (OIG) takes effort to keep track of the semiannual reports as well as the OIG Work Plan, which is fluid. During the 6-month period from April 1st and September 3 the OIG conducted a variety of work through and by the Office of Audit Services (OAS), Office of Evaluation and Inspections (OEI), Office of Investigations (OI), Office of Counsel to the Inspector General (OCIG), and Mission Support and Infrastructure (MSI). This HHS-OIG report released in November describes OIG’s work identifying significant risks, problems, abuses, deficiencies, remedies, and investigative outcomes relating to the administration of HHS programs and operations that were disclosed during the semiannual reporting period of April 1, 2022, through September 30, 2022.
The OIG reported that their audit work identified $62.9 million in expected recoveries as well as $612.6 million in questioned costs (costs questioned by OIG because of an alleged violation, costs not supported by adequate documentation, or expenditures of funds for which intended purposes were unnecessary or unreasonable). There was a lot of work directed at the COVID-10 public health emergency which is understandable. In addition, there was a lot of work conducted to ensure Nursing Home safety and to address the operational inadequacies within the Nursing Home setting.
Medicare Advantage (MA) risk adjustment continues to be a high target for inappropriate submission of diagnosis codes. The OIG has conducted work and published several reports including but not limited to the following:
- Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care (OEI-09-18-00260), April 2022;
- Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Cariten Health Plan, Inc., (Contract H4461) Submitted to CMS (A-02-20-01009), July 2022;
- CMS Has Opportunities To Strengthen States’ Oversight of Medicaid Managed Care Medical Loss Ratios (OEI-03-20-00231), September 2022; and
- Nearly All States Made Capitation Payments for Beneficiaries Who Were Concurrently Enrolled in a Medicaid Managed Care Program in Two States (A-05-20-00025), September 2022.
Another useful report is from the Department of Justice. The Department of Justice (DOJ) released its annual report of civil fraud recoveries for the prior fiscal year on February 7th, 2023. You might want to take a look at this report as well.
Remember to heed what your staff say about risks and compliance concerns as this can be of help for identifying issues and taking action. Be sure your hospital or healthcare facility has both internal and external auditing in place to be conducted on a regular basis. Follow that with education, both to providers, clinical documentation integrity (CDI) and medical coding staff.
My philosophy in regard to healthcare compliance is . . . you cannot be compliant and also be complacent about compliance. Take a pause and think about that and the complacency we see and hear each and every day. Management has got to be more proactive and not reactive to coding compliance in particular. Utilize the OIG semiannual report to help drive your compliance, both as an individual and as a department or company.
