It can be hard for medical practices to stay ahead of the OIG audit areas that are under scrutiny at any given time. One month, they’re targeting modifiers, and another month they’re homing in on global period claims. To stay on top of it, you need to be poring over their open issues almost every day.
To distill it down, check out five OIG audit focus areas that your practice must ace if you want to stay compliant.
1. Confirming Services Were Reasonable and Necessary
Your insurer will likely reimburse your claims if you put payable ICD-10-CM and CPT codes on them. But just because you’ve used payable codes on the claim, it doesn’t necessarily mean your services were reasonable and necessary. That’s where OIG audit scrutiny comes in. If an auditor reviews your claims and discovers that you performed services that weren’t medically necessary, you would need to repay the claim amounts and may even be subject to fines and penalties.
For instance, if you submit a claim for removing impacted cerumen but the payer reads your documentation and discovers that your provider swabbed out excess earwax, then your services would not be deemed reasonable and medically necessary. Swabbing out non-impacted earwax should be included in your E/M service and shouldn’t be billed with the impacted cerumen code.
2. Checking for Kickbacks, Self-Referrals and Inducements
During an OIG audit, reviewers want to make sure you aren’t getting kickbacks, inducements, or violating the self-referral laws in any way. For instance, if they see you’re sending every patient to a blood draw lab two towns away rather than one closer, they may wonder whether you have a non-compliant relationship with that particular lab. And if they find such a relationship, you could be subject to penalties and fines.
If you’re asked to refer patients in exchange for a kickback or another incentive — or if you’re referring patients somewhere that you or a family member owns — you could be violating these rules. Call an attorney right away to review these relationships and help you stay on the right side of the law.
3. Scrutinizing Improper Medical Record Documentation
Whether your documentation is missing the provider’s signature or you’ve forgotten to add a chief complaint, your documentation is considered incomplete. Every OIG audit starts with an auditor reviewing your documentation from beginning to end, so you must ensure that yours is thorough, complete, legible and contains all the details needed to support the codes you submitted on your claim form.
4. Checking for E/M “Clustering”
Some practices bill all of their E/M claims using the middle levels (such as 99203 and 99213) under the philosophy that some encounters will be higher, some will be lower, and the charges will average out over an extended time period. This is inappropriate, and every OIG audit representative will mark such claims as errors if they see them.
Instead, you should always bill the E/M level that reflects the documentation. If your documentation warrants 99212 or 99215, report those codes instead of the middle-level code, because that’s correct coding.
5. Confirming All Incident-to Requirements Were Met
Incident to billing is the most misunderstood and highly scrutinized billing area for most physician practices, and the OIG audit rep will be going through your documentation to make sure you met every requirement of these services.
For instance, if the nonphysician provider documents a new chief complaint but still bills the claim incident to, an auditor would mark that as inappropriate, since incident to only applies to established diagnoses. Or if an incident to claim is submitted on a date that no supervising doctors were present in the office, the auditor will ask you to repay the 15% incident to payment.
There’s so much more to know if you want to sail through your OIG audit every time. Let attorney Michael R. Lowe, Esq., help during his latest online training, Proven Tactics to Halt Costly Stark & Anti-Kickback Penalties. Register today!