The Merit of Auditing Healthcare Claims
Successful auditing of medical claims does not merely identify problems, it also pushes healthcare providers to bill honestly and follow coding and billing guidelines/regulations, assists in the prevention of improper payments, and reduces healthcare spending.
If audits are not being performed, there is no yardstick to measure the accuracy of proper reporting and billing of provider/supplier services and related reimbursement. Outcome analyses of audit findings is necessary to identify and assist with ongoing feedback, education, training and internal ongoing process improvements.
As healthcare costs continue to climb an upward slope, an escalated need exists for closer auditing of healthcare claims to identify egregious charges, improper medical coding and billing errors, duplicate billing, and associated improper claim payments.
Office of Inspector General (OIG) Audits
Since its establishment in 1976, the Office of Inspector General has been leading the forefront of the nation’s efforts to fight waste, fraud and abuse and improve the efficiency of the Medicare, Medicaid and numerous other Health and Human Services programs.
The OIG Work Plan, reports and publications outline its activities and achievements, as well as its ongoing and planned areas of audit focus. Through ongoing assessments, the OIG prioritizes issues posing threats to Medicare trust funds. Subsequently it allocates resources to conduct audits targeting those issues in its OIG Work Plan, which is updated monthly to address emerging issues.
Below are some of the listed 2024 OIG Active Work Plan Items:
- Medicare inpatient hospital billing for sepsis
- Comparative analysis between Medicare payments and Hospital’s published prices
- Joint pain management therapies: Hyaluronic acid knee injections
- Medicare payment for clinical laboratory tests in 2023
- Medicare payments for lower extremity peripheral vascular procedures
- Durable medical equipment, prosthetics, orthotics and supplies fraud and safeguards in Medicare
- Nationwide audits of organ procurement organizations and certified transplant centers
- Nursing facility drug overdoses
- Diabetes drugs under Medicare Part D
- Optometrists billing for Part B services for Medicare enrollees in nursing facilities
It is beneficial to monitor the OIG Work Plan to identify billing practices flagged as high risk for fraud and abuse. Additionally, the OIG creates consumer fraud alerts, advisory opinions and audit reports that influence auditing behavior among Medicare administrative contractors and commercial payers.
If you don’t believe the OIG is serious about fighting healthcare waste, fraud and abuse refer to https://oig.hhs.gov/fraud/enforcement/ and review the list of enforcement actions —providers/supplies that have been hit with criminal, civil or administrative legal actions relating to fraud and other alleged violations of the law, initiated or investigated by the OIG and its law enforcement partners. The OIG additionally maintains a list of all currently excluded individuals and entities. Anyone who hires an individual or entity on the LEIE may be subject to civil money penalties.
Healthcare Claims Auditing
Claims auditing should be a core function whether part of an ongoing compliance program, payment integrity program, risk reduction program, fiduciary responsibility or other, depending on the organization.
Medical claim audits provide a mechanism to:
- Identify coding/billing and reimbursement errors, patterns, and trends
- Recognize specific areas of concern for ongoing internal process improvement
- Determine if internal policies/procedures are needed and/or are current and effective
- Ensure appropriate revenue is captured
- Minimize risk
- Identify if potential provider/supplier repayment(s) are applicable
- Provide legal defense
The Takeaway
Claim audits continue to be an essential tool in the toolbox. Ignorance is a liability. Pervasive error pattern(s) resulting in higher reimbursement than a provider is entitled is fraud. A fair and efficient system, ongoing compliance management, ongoing process improvements, fairness and accuracy of payments benefits everyone.
Under ERISA laws, it is imperative healthcare claims are audited to verify claim pricing and payments, a key duty to fulfill fiduciary responsibilities. ClaimDOC takes this very seriously.
Ethical responsibility requires healthcare providers to have ongoing and effective coding/billing compliance programs as well as maintaining price transparency and fairness in billing practices.
Given the volume of healthcare claims that are reported/billed each day by providers/suppliers, medical bills errors and egregious charges are alarmingly common and lead to abuse, waste and fraud.
When an individual receives a healthcare bill that appears questionable/inappropriate, an inquiry to the provider and/or health plan should be made to obtain an explanation of the service(s) and corresponding charges.
Background
ClaimDOC’s comprehensive line-by-line review of claims uncovers errors that basic claim repricing and auto-adjudication does not catch, leading to greater savings for health plans and its plan members. Our audit team analyzes all types of healthcare claims for a variety of potential concerns including excessive usual and customary charges, duplication of claims, double billing of services, incorrect coding, incorrect quantity units, unbundling of services and many others. Our claims review is not intended to impact care decisions or medical practice.
Our goal at ClaimDOC is to use benchmark charges and costs nationally to negotiate fair and ethical payments. Our high-quality and expert auditing of claims identifies and prevents improper medical claim payments and maximizes long-term cost savings opportunities. Employers turn to us seeking to establish fair reimbursement rates for their plans allowing them to save money and provide richer benefits to their employees. A win-win for everyone.