If the OIG makes a visit, don’t be caught off-guard
Subpoenas can be settled sans penalty, expert says
What will you do if representatives from the federal Office of the Inspector General (OIG) come to your hospital seeking information? Will you start crying, call your attorney, or refuse to talk?
Claudia Jones, access manager at Scripps Memorial Hospital in Chula Vista, CA, faced just that dilemma recently when the OIG contacted her hospital’s health information management (HIM) department and asked for the medical record of a specific behavioral health patient. The OIG visit apparently was part of an audit of patients who had received outpatient care for behavioral health problems.
Jones says she later learned that another of ScrippsHealth’s six hospitals was contacted. That hospital was asked for four records, while her facility had just one record request, she adds. Other facilities throughout San Diego County also got visits.
"My first reaction was fear," says Jones, who was serving as acting HIM director. "What was freaky for me was that I don’t know anything about behavioral health records. They have different requirements than regular medical records. I wanted to make sure all my billing dates matched up with physician or therapist documentation."
During the visit to Scripps Memorial, she says, the OIG representative, who was accompanied by another government official, sat in a closed office. The OIG representative gave her his business card and a copy of the federal regulation giving him the authority to view the record, Jones adds.
"If it happened again, I would also get a signed authorization," she says. "There is a regulation that states we must give them the chance to view and get a copy of the record, but for my own protection, I would get [the representative’s] badge number and have him sign a standard release and keep a copy of that with the record."
The OIG representative requested a roster of all the hospital’s physicians and a document from the medical staff office, to check a physician’s signature against the record, Jones recalls. He also asked for the UB-92 form for the account in question, she notes.
The visit occurred around the first of February, she says, and there’s been no further word on the investigation. "I couldn’t even guesstimate when we’ll hear back from them. They did say these [investigations] were going to become more frequent."
Don’t fear simple errors’
Despite the new climate of investigation and the initial panic it sparked, health care managers shouldn’t be afraid of penalties for making a simple error, says Melissa Ferron, principal of Melissa Ferron Healthcare Consulting in Redondo Beach, CA. "For the most part, hospitals are doing the right thing," she says.
"Be afraid if you discover upcoding to game the system for additional reimbursement," she cautions. "The recent OIG investigations are a warning to everyone that your staff needs to be educated on how important it is to be error-free and to follow official guidelines.
"None of the hospitals I’ve been through an investigation with are nervous about having to shut their doors," Ferron says. "Even those who have paid back a lot of money don’t feel their doors will be closed."
She says she has helped clients through a couple of different fraud and abuse investigations in Southern California, including one targeted at diagnosis-related group (DRG) miscoding. That investigation, which began more than 18 months ago, looked specifically at 482.89, the code for bacterial pneumonia, when it is used instead of the lower-weighted code 486, which is for unspecified pneumonia, she explains.
California was one of 12 states chosen for the investigation, she says. "Apparently, the national average for coding 482.89 is 3% of all pneumonia cases. Hospitals deviating from this average are the facilities that are being subjected to the investigation."
Includes additional documents
The subpoenas served as part of the investigation requested not only copies of medical records, which numbered in the hundreds, but also outlined an assortment of additional documents, Ferron notes. "The list of medical records comes with admission and discharge dates and HIC number. That’s it — no names. And the records date back to October 1992, which was when the code 482.89 first came into use."
The documents requested for each case included, in part, "the patient’s admission report, discharge summary, physician notes and orders, lab reports, culture reports, and any other documents used by the hospital billing department to determine the appropriate diagnostic and DRG billing codes," she adds, quoting from the extensive list accompanying the subpoenas.
The subpoenas also asked for, from January 1991 to the present, all organizational charts for the billing department and all documents containing job descriptions or detailing the responsibilities for each employee involved in billing and/or coding, Ferron says.
Requesting a plethora of paper
In one lengthy paragraph, the subpoena requests, among other items, "reports, correspondence, notes, memoranda, guidelines, directives, training materials, minutes of meetings, analyses, audits, manuals, policies, calendars, working papers, contracts with consultants, charts, graphs, drawings, electronic mail, voice mail message recordings, facsimiles, telegrams, videotapes . . . relating to the hospital’s billing and/or coding of Medicare claims for the treatment of patients with pneumonia."
Hospitals were given a month to gather the information and provide it to the OIG, Ferron says. "You do the best you can and hope you gave them everything."
One hospital, she recalls, had used an outside consultant for coding, and the company had since become defunct. "Nobody can find them, but the hospital still may be ultimately responsible."
In some cases, she says, the hospitals involved conducted internal audits to assess their liability and paid back the money owed. "It may be possible to settle with the subpoenas without penalty."
The government has designated California Medical Review Inc., the peer review organization (PRO) for California, to identify and reduce errors in Medicare inpatient claims. That may include auditing registration and discharge processes, billing, and coding at the hospitals the PRO oversees, Ferron points out.
An increased effort at reducing errors has made government officials realize just how complex coding is, she suggests. "The government wants the PRO to look for a pattern of upcoding on a more concurrent basis. Charts will be requested and reviewed, and statistical analysis may be performed to identify facilities falling outside the norm."
Turn it in on time
For a health care organization served with a subpoena that requests medical records or other documents, Ferron says, her first piece of advice is to get the material to the specified address on time.
"You’re normally given a time limit, and you need to be pretty well-organized to meet it," she explains. "It’s best to identify one person to send it all out, whether the material is from the business office or from medical records. This can be the risk manager, the compliance officer, the health information manager, or the business manager. Don’t have too many hands stirring the pot."
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