HCPro.com: Health Care Auditing Strategies

July 2008 (Volume 7, Issue 7)	view entire issue

New York's new work plan offers audit cheat sheet
The detailed work plan released on April 22 by New York's Office of the Medicaid Inspector General (OMIG) offers valuable guidelines for New York providers. It also gives clues to what may be in store in other regions of the country, says Ed Kornreich, partner at New York City-based Proskauer Rose, LLP. "In most other states, there is already an awareness of some of the issues featured in this work plan, such as quality, because of national initiatives," Kornreich says. "I do think this kind of approach, using Medicaid Inspector Generals and work plans, will be replicated in other states and will eventually become the standard."

OIG increases oversight for Medicaid mental health
The Deficit Reduction Act of 2005 (DRA) brought significant changes to reimbursement for medical care and increased scrutiny of healthcare compliance. Included with these changes are new Medicaid rules that mental health professionals must follow. Not all the changes proposed in the DRA are currently in effect. The rehabilitation requirements presently under legislative moratorium are scheduled to take effect June 30. The potential cost of failing to comply is huge compared to the penalties of the past. Previously, if CMS detected a billing error, the cost was normally limited to the amount of the error-this is no longer the case, says Terry Haru, chief compliance officer at Heritage Behavioral Health Center in Decatur, IL.

OIG attention on DSH payment program escalates
The OIG has focused its attention on the Medicaid Disproportionate Share Hospital (DSH) Payment Program in its annual Work Plan for the past several years. This year is no different. Prompted by rapidly growing state DSH expenditures, the OIG highlighted several areas it is focused on this year. The DSH requirement mandates additional funds from state Medicaid programs for hospitals that serve a disproportionate number of low-income patients-known as a DSH payment adjustment-in order to supplement their revenue stream. CMS gives each state significant leeway in both defining DSH hospitals and its methods of DSH payment.

Patient status: Five tools to conduct internal audits
Editor's note: This article is the first in a two-part series on patient status. In an era of greater accountability and enforcement, hospitals and treating physicians will be increasingly responsible for complying with Medicare's medical necessity criteria for admissions and determining patient status. Exercise oversight methods To improve patient care and reduce the occurrence of claims denials or underpayments, hospitals need to employ several careful oversight procedures, including: Retrospective guidance of its utilization review (UR) committee Internal audits Prospective guidance of case management protocol (CMP)

Other recently-published articles from Health Care Auditing Strategies:

Timing is important when auditing observation status

Five tips to audit coders for compliant claims

Be prepared for RACs with internal audits

Medicaid integrity contractor audits soon to follow RACs

Clinical documentation programs result in fewer errors, improved compliance

CMP may serve as solution to patient status concerns

Conducting an internal investigation interview

A proactive approach to self-disclosure

Methods of issuing IM on discharge appeal rights vary

A four-step approach to a risk management plan

CMS stops payment for eight HACs; more to come

Patient status: Five tools to conduct internal audits

OIG attention on DSH payment program escalates

OIG increases oversight for Medicaid mental health

New York’s new work plan offers audit cheat sheet

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