Despite the pandemic, the U.S. Department of Health and Human Services – Office of the Inspector General (HHS-OIG) has not missed a beat. Regulators are still focusing on fraud and non-compliance. This article refers to a bulletin, issued in February 2021, that focuses on inappropriate billing. Even though it has to do with Medicare inpatient stays, the information should still raise a flag for all providers because COVID or not, government agencies are still going about business as usual.
You might be surprised to learn that even before the pandemic, it was reported that Medicare paid $109.8 billion for 8.7 million inpatient hospital stays in 2019. Add COVID to the mix and you can understand why regulators need to make sure that every Medicare dollar is spent properly and legitimately.
Although this recent report is limited to inpatient claims, it reinforces that all providers need to ensure – when billing any insurance – that there is documented medical necessity for all procedure codes, modifiers, diagnosis codes, etc. In another blog, we summarized a different OIG report that concluded Medicare did not use its own error rate data to target error-prone providers, 100 of which received $3.5 million in overpayments and experienced a 60.7% error rate – much higher than the national average of 11.3% for all Medicare providers.
This is why we urge every medical practice, hospital and healthcare business to conduct regular audits to safeguard against fraudulent claims and identify any issues before they become problematic. The most successful clients employ a combination of internal and external reviews to make sure they’re prepared to have any of these government agencies stop in and conduct a review.
It’s important not to overlook the emphasis in the article on protected health information (PHI) and HHS-OIG’s “Cybersecurity Team,” established to fight against all cyber fraud. With the proliferation of EHRs and telehealth, more and more services are being delivered online, and cybersecurity related fraud may be another area where False Claims Act activity may be evident. Make sure your audits touch on the documentation and provision of telehealth services too.