OIG Compliance
News and Important Information
An Update on the DHS OIG's Effort to Combat Fraud % Abuse
OIG Announces New Review for Medicare Part B Payments for Podiatry and Ancillary Services
Resources
General Links and Resources
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Sep 8th, 2022
Are You Prepared to Avoid Repayments
by Raquel Shumway
Watchful care is needed when submitting claims.
The Office of the Inspector General (OIG), after completing an audit on a Medicare Advantage Plan in August 2022, is now demanding repayment of claims to the tune of $3,518,465. Although the payer is contesting that amount, it is possible that they may begin demanding repayments from the providers to cover their costs of repayment.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
We all experience coding situations that make us stop and rethink our coding path. Do we have the most current information on this situation? Does the payer contract change the way we must report the service? Are we missing something? Each of us experience simple to complex coding issues in our work and sometimes it is just nice to collaborate and discuss them openly to see how they may be resolved. Have you ever questioned the proper use of major depressive disorder codes versus the newly added (2021) depression, unspecified code? Take a look at what the OIG said about these codes and how the payer responded.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
There are many lessons that can be learned from a single OIG audit report. In this recently-published OIG report, several of the most common documentation and coding errors are pointed out in relation to reporting HCCs for risk adjusted plans. Take a few minutes to review the report and see if improvements within your own organization can be made from what you learn.
by Raquel Shumway
DynamiCare Health Inc. has developed a contingency management program for those dealing with substance use disorders. DynamiCare Health Inc. has developed a contingency management program for those dealing with substance use disorders. CM “addresses the brain’s reward response in ways that conventional counseling and medications often cannot.” Over a course of 50 years, it has shown that this program is effective. The OIG, upon analysis, has determined that there is low risk for fraud and abuse and has offered their opinion at the request of DynamiCare Health, Inc.
Apr 12th, 2022
Monitoring Changes to Telehealth in 2022
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
SUMMARY: Did you realize telehealth services increased by 11,000% between 2019-2020? Once again the newest CPT and HCPCS updates address telehealth changes for 2022 with new modifiers and guidelines for reporting. With such an increase in usage, the OIG has also identified significant fraud.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
As the OIG has published their intent to further investigate the 9.5% of improper payments based on incorrect ICD-10-CM code assignation, they implore Managed Care Organizations (MCOs) to begin employing some of the CMS tools and data analytic programs used to help identify outliers.
by Jared Staheli, MPP
The Office of Inspector General for the United States Department of Health and Human Services (HHS-OIG) is responsible for ensuring the integrity of programs operated by HHS, including the Medicare and Medicaid programs. One of the ways this is accomplished is through the identification of fraudulent activities, one of which ...
Oct 27th, 2020
OIG – Fraud and Abuse Study with COVID-19 Testing
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
According to the Office of Inspector General (OIG), “The coronavirus disease 2019 (COVID-19) pandemic has led to an unprecedented demand for diagnostic laboratory testing to determine whether an individual has the virus. Beyond the COVID-19 tests, laboratories can also perform add-on tests, for example, to confirm or rule out diagnoses ...
Jul 28th, 2020
OIG Report Highlights Need to Understand Guidelines
by Wyn Staheli, Director of Content - innoviHealth
A new OIG report once again highlights the necessity for organizations to fully understand requirements for reporting services and having proper documentation. The types of problems addressed in this report are ongoing issues for multiple types of services and specialties and for many different payers.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
We attended the recent virtual RISE National Conference and had the opportunity to listen to presenters share their knowledge about risk adjustment and HCC reporting and data validation. Among the presenters were representatives from the Office of Inspector General (OIG), who presented findings from encounter data from 2012-2016. They began ...
Apr 20th, 2020
Now That is Fraud! Genetic Testing "Public alert"
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Genetic testing is becoming very popular. In fact, so popular you might see it in places you would not expect such as a community event, fairs or any event happening in your community. Some labs may even offer FREE screening for genetic testing. Watch for FREE screening announcements or advertisements ...
Aug 9th, 2019
The OIG Work Plan: What Is It and Why Should I Care?
by NAMAS
The Department of Health and Human Services (HHS) founded its Office of Inspector General (OIG) in 1976 and tasked it with the responsibility to combat waste, fraud, and abuse within Medicare, Medicaid, and the other HHS programs. With approximately 1,600 employees, HHS OIG is the largest inspector general's office within ...
May 17th, 2019
An Update on the DHS OIG's Effort to Combat Fraud & Abuse
by NAMAS
An Update on the DHS OIG's Effort to Combat Fraud & Abuse
Every year, the Department of Health and Human Services (DHS) Office of Inspector General (OIG) is required by law to release a report detailing the amounts deposited and appropriated to the Medicare Trust Fund, and the source of such ...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Due to prior OIG work identifying inappropriate payments for podiatrists and ancillary services, the OIG announced in Feb 2019 they will begin a new review starting in 2020. The OIG stated they will review Medicare Part B payments to determine if medical necessity is supported in accordance with Medicare requirements.
Part of the ...
Apr 23rd, 2018
Brooklyn Chiropractor OIG Report - Lessons Learned
by Wyn Staheli, Director of Content - innoviHealth and Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow
In August of 2017, a Brooklyn chiropractor was ordered to repay $672,805 to Medicare because the reviewer found that 100% of the claims reviewed (from 2011-2012) did not meet medical necessity requirements. The chiropractor enlisted help from two reputable experts who disputed the findings of Medicare’s Professional Reviewer (MPR). However, the OIG maintained that the findings of the original auditor were valid.
Since none of us have ½ million in cash just laying around, it is essential to learn, understand, and make changes where appropriate to help audit-proof patient documentation.
Read here to learn more.
Dec 21st, 2017
OIG Advisory Opinion Recinded - Lessons Learned
by Wyn Staheli, Director of Content - innoviHealth
In the compliance world, it is important to know when the OIG makes an advisory opinion on a subject. For example, the advisory on Time of Service or Prompt Pay Discounts helps to ensure that providers are creating policies and procedures which will meet the standards of the OIG in the case ...
Oct 23rd, 2017
Summary of OIG Reports for Chiropractic
by Wyn Staheli, Director of Content - innoviHealth
The Office of the Inspector General was created to protect the integrity of the U.S. Department of Health and Human Services. They investigate fraud, waste, and abuse in HHS programs and make recommendations to various enforcement agencies. Every few years they investigate chiropractic services. Here is a summary of the reports the ...
Jul 31st, 2017
Health Care Fraud - Don’t Do It!
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
If you wonder if what you are doing is fraud, DON’T DO IT! The government takes this extremely serious. I don't need to tell you this.
I have often been apprehensive about making a mistake and I wonder, will it be fraud? Will I spend time in jail for accidentally sending in a duplicate ...
Select the title to see a summary and a link to the full webinar information. some webinars require a subscription to view.
May 10th, 2022
Exclusions: What They Mean to You
by Ron Short, DC MCS-P CPC
May 5th, 2022
Do Minor Procedures Feel like Major Work?
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Sep 11th, 2019
Inappropriate Payments Made to Chiropractors – An OIG Review
by Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow
In this webinar, Dr. Gwilliam will take you on a fun filled journey through all of the reports created by the Office of the Inspector General based on their reviews of chiropractors. If you can understand what they see, and what advice they give Medicare when dealing with chiropractors, then you will be better prepared to not become their next target. This webinar may feel a little frightening with hundreds of thousands of dollars paid back to CMS, but, by the end, you will know exactly what to do and what not to do.Links and resources by topic.
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