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So Many Changes: New Data, Strategy, and Technology Don’t Forget The Basics

The OIG’s audits are ramping back up based on their work plan. Obviously, they will be focused on telehealth and supervision, but don’t forget about the integrated basics.


Hospitals, providers, and departments don’t have the budget is what I am currently hearing from so many managers, directors, and administrators. (This is where OncoSpark steps up) COVID has disrupted departmental operations/structure at the clinical and the ancillary staff level-------- from places of service, to supervision, and to policy and requirement changes.


This has increased risk.... Other things that I am hearing are:


  • That is what our scrubbers and our software is for (generally this data is not unified and is applied to all service lines, which is highly inaccurate at scale, giving false sense of compliance)
  • We just don’t have time (if this workflow is hardwired and transparent, little to no time is added)
  • We have an AI program (AI / ML / RPA often reviews data in the EHR ecosystem. This data is often not structured or clean, which will render these programs inaccurate when solely deployed.


This will not be an excuse as the audits are conducted.


What is coded and what is billed is often different and data may pass through several programs and platforms before export. Most importantly, you need to have more than just software that looks at rules, NCCIs, and MUEs.


The relationship must be made between the code, orders, documentation, medical necessity for validated/support codes that went out on the claim. Functional clinical expertise plus rule/reg. knowledge is required to ensure risk mitigation as well as opportunity discovery.


This is what we have done in Oncology- Infusion, Radiation Oncology, Medical Oncology and Asthma & Allergy. Expertise combined with technology & data empathy to isolate and make the data relational and actionable.


Why it Matters: FULL REPORT


Our (OIG) audit covered about $41 million in Medicare payments to the Hospital for 2,117 claims that were potentially at risk for billing errors. We selected for review a stratified random sample of 85 inpatient and 15 outpatient claims with payments totaling $2.4 million for our 2-year audit period (January 1, 2017, through December 31, 2018). The Hospital complied with Medicare billing requirements for 46 of the 100 inpatient and outpatient claims we reviewed. However, the Hospital did not fully comply with Medicare billing requirements for the remaining 54 claims, resulting in net overpayments of $999,950 for the audit period. Specifically, 50 inpatient claims and 4 outpatient claims had billing errors.


Recommendation: refund to the Medicare contractor $23.6 million in net estimated overpayments


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