Look for these areas of risk in your practice
Look for these areas of risk in your practice
OIG cites most frequent subjects of investigations
The Office of the Inspector General (OIG) cites the following areas that are most frequent subject of investigations of physician practices:
• Billing and coding. Areas you should look at include:
— billing for items or services not rendered or not provided as claimed;
— submitting claims for equipment, medical supplies, and services that are not reasonable and necessary;
— double billing and billing for noncovered services;
— knowing misuse of provident identification numbers, resulting in improper billing;
— billing for unbundled services;
— failure to properly use coding modifiers;
— upcoding the level of service provided.
• Reasonable and necessary services. The OIG reminds physicians that Medicare will pay only for services that meet the Medicare definition of reasonable and necessary. Practices should be able to provide documentation, such as patient medical records and physician’s orders, to support the appropriateness of services, the OIG says.
• Documentation. Inappropriate documentation of diagnosis and treatment is the leading cause of inappropriate payments, the OIG says. The guidance cites two areas of concern: medical record documentation and proper completion of the Health Care Financing Administration (HCFA) 1500 Form. Current procedural terminology and ICD-9 codes on the claims form should be supported by the documentation of the medical record, and HCFA should be able to determine who provided the services.
• Kickbacks, inducements, and self-referrals. Your practice should have policies to ensure that you comply with the anti-kickback statutes and the physicians self-referral law, particularly in regard to your arrangements with hospitals, hospices, nursing facilities, home health agencies, durable medical equipment suppliers, and vendors. Improper inducement may include waiving co-insurance without ensuring that the patient is in financial need or failing to make an effort to collect the cost-sharing amount, the OIG says.
• Retention of records. Your practice should make it a priority to keep business and patient records as well as documentation of compliance-related activities. Keep all correspondence with Medicare carriers. This involves, at minimum, keeping an updated binder that contains information on compliance meetings, educational activities, and internal audit results.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.