MDaudit regularly tracks new work items added by The Office of Inspector General (OIG), to provide the most comprehensive support with our continuous risk monitoring platform. This year’s work plans have introduced several new areas of focus that will impact healthcare providers across the United States.
By incorporating these key points from the 2024 OIG Work Plan into your auditing and compliance strategies, MDaudit can help your organization navigate the complexities of healthcare billing with confidence and precision.
Here’s how we can assist with the latest OIG directives
Sepsis-Related Billing Scrutiny
Earlier this year the OIG added a new work item to highly scrutinize sepsis-related billing. Sepsis is a frequently billed diagnosis in Medicare claims. The OIG has raised concerns that hospitals may be taking advantage of this broader definition, as they have a financial incentive to do so. Their study will analyze Medicare claims to assess patterns in the inpatient hospital billing of sepsis in 2023 and describe how the billing of sepsis varied among hospitals.
This increased scrutiny means that healthcare providers must ensure their billing practices for sepsis cases are both compliant and optimized for revenue generation. MDaudit offers robust tools to audit sepsis-related claims meticulously, ensuring that all billing is compliant with the latest guidelines while also maximizing reimbursement.
Utilization of Peripheral Vascular Procedures
The OIG has also included the Utilization of Peripheral Vascular Procedures and CMS’s Related Program Integrity Efforts in its work plan. In 2022, Medicare paid more than $600 million for atherectomies and angioplasties with and without a stent in peripheral arteries. CMS and whistleblower fraud investigations have identified these surgeries as vulnerable to improper payments. This focus can lead to increased external audits and potential denials if billing practices are not up to standard. MDaudit provides healthcare organizations with the capabilities to preemptively audit and analyze peripheral vascular procedure claims, ensuring compliance while reducing the risk of claim delays and denials.
Lower Extremity Peripheral Vascular Procedures
The use of peripheral vascular procedures in an office setting has increased among the Medicare population over the past decade. For the calendar years 2022 and 2023, Medicare paid approximately $1.16 billion for lower extremity peripheral vascular procedures in office settings. These minimally invasive procedures aim to improve blood flow when arteries narrow or become blocked because of peripheral arterial disease but are generally recommended only after patients have tried medical and exercise therapy and have lifestyle-limiting symptoms. In addition, CMS and whistleblower fraud investigations have identified these procedures as vulnerable to improper payments.
MDaudit’s Denials Predictor is a pre-payment charge review engine for high dollar claims to augment claim scrubbers for high specialty drugs, implants, and complex diagnoses across hospital and ambulatory surgical centers (ASCs) and can be customized with rules to identify medical necessity and treatment coverage issues that may be denied based on payer policies.
Medicare Advantage Fraud
Recently, a new impact brief from the OIG highlights significant outcomes of oversight related to Medicare Advantage fraud. Accurate coding and submission of Conditions and Complications (CCs), Major Complications and Comorbidities (MCCs), and Hierarchical Condition Categories (HCCs) are crucial, especially for claims submitted to Medicare Advantage Plans.
MDaudit ensures that these codes are submitted with the highest levels of accuracy and integrity, thereby minimizing the risk of increased scrutiny around fraudulent Medicare claims, enhancing compliance, and protecting revenue.
Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) During Inpatient Stays
The OIG’s latest work plan now includes scrutiny of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) provided by suppliers during inpatient stays. Overlapping claims can happen when an enrollee receives a DMEPOS item during an inpatient stay at an acute-care hospital. In general, certain items, supplies, and services furnished to inpatients are covered under Medicare Part A and should not be billed separately to Medicare Part B. For providers with a significant Medicare Part A and B payer mix, it is essential to verify that DMEPOS are billed correctly to Medicare Part A (for inpatient services) rather than Medicare Part B (for outpatient services).
MDaudit can automate the identification and random sampling of these claims, facilitating timely audits that ensure DMEPOS are billed compliantly and reimbursed accurately.
Protecting Revenue with Continuous Risk Monitoring
MDaudit’s continuous risk-monitoring SaaS platform is a vital tool for healthcare providers aiming to navigate OIG scrutiny while protecting their revenue. By integrating MDaudit into your compliance and auditing processes, your organization can:
- Proactively identify and address compliance issues before they escalate.
- Ensure accurate and compliant billing practices.
- Maintain financial health through optimized revenue integrity strategies.
Incorporating these 2024 OIG Work Plan updates into your auditing and compliance strategies with our platform ensures that your organization can navigate the complexities of healthcare billing with confidence and precision. As the OIG Work Plan evolves, we remain a steadfast partner in ensuring your organization is compliant and financially sound.
