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Whether you are dealing with a commercial payer, Medicare, or Medicaid, there are certain types of improper claims that should be avoided if you want to reduce your risk of a medical coding audit. That bit of wisdom comes from an entity that ought to know: the U.S. Department of Health and Human Services’ Office of the Inspector General (OIG).
The OIG has released a roadmap to help new physicians avoid medical billing fraud and abuse in the Medicare and Medicaid programs. But this advice also broadly applies to how you approach reimbursement from commercial payers, and can also serve as a helpful reminder for physicians with years of experience in practice.
The agency warns, sternly, about consequences, noting in bold type that “when the federal government covers items or services rendered to Medicare and Medicaid beneficiaries, the federal fraud and abuse laws apply.”
When it comes to medical coding errors, the broad categories of “fraud” and “abuse” have distinct meanings. Fraud involves intentional misrepresentation. Abuse means “the falsification was an innocent mistake, but nonetheless representative,” according to the AMA’s Principles of CPT® Coding, ninth edition.
Medicare and Medicaid audits are an extremely popular topic. Imagining the possibility of having your practice or hospital audited for its billing practices is a daunting thought. How simple it can be for a practice to overlook a coding change to IDC-10 or suddenly fall behind the latest PHI requirements.
Failure to stay on top of the changing landscape can lead to major financial problems down the road and the need to pay back unallowable funds. Daily we hear of OIG audits that are the results of missing a coding change or improper practice policies that can be catastrophic to the financial well being of a healthcare organization.
A few weeks ago The AAFP released its initial summary(2 page PDF) of the proposed 2019 Medicare physician fee schedule which, for the first time, also includes recommended changes that would affect CMS' Quality Payment Program in 2019. Is this good or bad for you? Let me share some quotes from the AAFP website that can be found here: https://www.aafp.org/news/government-medicine/20180724mpfssumm.html
This proposed rule would revise the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2019 to implement changes arising from our continuing experience with these systems. In this proposed rule, we describe the proposed changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system. In addition, this proposed rule would update and refine the requirements for the Hospital Outpatient Quality Reporting (OQR) Program and the ASC Quality Reporting (ASCQR) Program. The proposed rule also includes requests for information on promoting interoperability and electronic health care information exchange, improving beneficiary access to provider and supplier charge information, and leveraging the authority for the Competitive Acquisition Program (CAP) for Part B drugs and biologicals for a potential CMS Innovation Center model. In addition, we are proposing to modify the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey measure under the Hospital Inpatient Quality Reporting (IQR) Program by removing the Communication about Pain questions.
In today’s regulatory revenue cycle climate the stakes are too high to ignore the importance of a medical coding compliance plan. Engineering a solid plan can help protect practice professionals from penalties. Creating and adhering to a plan can make the difference in fraud and abuse determinations.