Posts Tagged ‘audits’
The OIG audited 21 specific DRGs—and found heavy error rates with these four
The Office of Inspector General (OIG) released results of three acute care hospital audits with a combined $35M in recommended recoupments. 21 specific DRGs were the target, four of which landed squarely in the bullseye. SVP of Solutions Jason Jobes identified the OIG’s targets, methodology, findings, explained their extrapolation methodology, and offered strategies for risk…
Read MoreOIG offers clinical scenarios that can illuminate your own audit vulnerabilities
The recent Office of Inspector General (OIG) audits of three acute-care hospitals offer a goldmine of clinical/coding examples that you should be using for pre-emptive audit defense. Validating DRG assignments, reviewing medical necessity documentation completeness, and educating providers before an auditor comes knocking—and uses extrapolation to greatly increase recoupments. Here are examples taken from the…
Read MoreMedicare Advantage plans: Should healthcare organizations care about payer audits, fines? Hint: Yes
You are a CDI Director at a large integrated healthcare system, with oversight of staff working in acute care hospitals and clinics. You have patients with Aetna and Kaiser Permanente. Then the news hits: Kaiser agrees to pay $556M to settle false claims act (FCA) allegations for inflated risk adjustment coding. Aetna, $117M for similar…
Read MoreYou need to have it both ways: Audits must target missed coding opportunities and invalid conditions in risk adjustment
By Brian Murphy Among the alleged behaviors that led to Kaiser’s eventual $556M payout to settle false claims act allegations was its aggressive effort to only add diagnosis codes (up to a year or more after the encounter) and never remove them. This is called a one-way audit, and the Department of Justice does not…
Read MoreTrump administration’s appeal of vacated RADV rule indicates Medicare Advantage audits not going away
By Brian Murphy Nothing is over. We’re still deep in the wild west of Medicare Advantage (MA). In case you missed the breaking news over the Thanksgiving break, the Trump administration on Friday appealed a crucial court decision. In September a TX judge ordered the 2023 Risk Adjustment Data Validation (RADV) rule vacated, removing CMS’…
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