ED Coding & Reimbursement Alert - 2007 Issue 9
HOSPITALS: Prepare For More Scrutiny Of Your Outpatient Billing
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Article Overview
This article summarizes major hospital billing and payment oversight topics highlighted in the OIG 2007 Work Plan. It is relevant to hospital compliance, billing, reimbursement, and audit teams that need to understand the broad categories of Medicare scrutiny affecting inpatient and outpatient hospital services, payment accuracy, charge-related issues, and specialty hospital oversight.
Why This Topic Matters
It helps hospitals and revenue cycle teams identify where federal auditors and program integrity efforts may focus, so they can review internal billing, documentation, and charge capture processes before claims are examined more closely.
Article Sections
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Dialysis admissions and observation status
Discusses review activity related to dialysis stays and the distinction between inpatient and observation-level care in hospital billing oversight.
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Inpatient PPS wage indices
Covers planned review of wage data used in inpatient prospective payment calculations and the potential impact of hospital-reported data on payment accuracy.
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Inpatient hospital payments for new technologies
Describes examination of payment and cost issues for newly introduced hospital services and technologies under Medicare payment systems.
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Outpatient department payments
Summarizes planned scrutiny of hospital outpatient department payment practices under the outpatient prospective payment system.
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Outpatient outlier and charge-related issues
Addresses review of outlier and other charge-related payment issues affecting hospital outpatient departments and community mental-health centers.
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Unbundling of hospital outpatient services
Covers concern about services that may have been billed separately when they are expected to be part of outpatient hospital services.
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Inpatient-only services performed in an outpatient setting
Discusses oversight of denied or disputed services that fall into an inpatient-only category when performed in outpatient settings, along with claims-processing edits.
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Diagnostic x-rays in emergency departments
Describes planned review of payment practices involving diagnostic imaging interpreted in hospital emergency departments.
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Oversight of specialty hospitals
Summarizes CMS and OIG attention to physician-owned specialty hospitals, including patient safety, quality, and staffing-related review areas.
What You Will Learn
- The major Medicare hospital billing and payment areas highlighted in the OIG work plan
- How federal oversight efforts can affect both inpatient and outpatient hospital claims
- Which hospital service categories are likely to receive closer review
- What broad compliance areas hospital billing teams should monitor
- Why documentation and payment accuracy matter in audit-focused environments
Who Should Read This
- Hospital billing departments
- Hospital compliance officers
- Revenue cycle teams
- Medicare auditors and reviewers
- Health care reimbursement professionals
- Coding professionals
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