Deeper Than The Headlines: OIG Hospital Review Case Studies

Last week, the OIG posted a report of their Medicare Compliance Review of the University of Florida Health Jacksonville Hospital. This is the most recent of many similar reports.

OIG has been performing these hospital compliance reviews for many years now. Reviewing them in greater depth can give your compliance program an idea of the types of claims the OIG is reviewing.

For those who are unfamiliar with these reviews, the OIG has provided the following as rationale:

“This review is part of a series of hospital compliance reviews. Using computer matching, data mining, and other data analysis techniques, we identified hospital claims that were at risk for noncompliance with Medicare billing requirements. For the calendar year 2014, Medicare paid hospitals $159 billion, which represents 46 percent of all fee-for-service payments. Therefore, the Office of Inspector General (OIG) must provide continual and adequate oversight of Medicare payments to hospitals.”

Many of these reviews have covered both inpatient and outpatient claims. However, this particular review only included inpatient claims. The hospital is a 695-bed, not-for-profit hospital, located in Jacksonville, Florida. According to CMS's National Claims History data, Medicare paid the Hospital approximately $167 million for 11,134 inpatient claims paid from January 2013, through September 2014, (audit period). The OIG’s audit covered $13,858,253 in Medicare payments to the Hospital for 1,305 inpatient claims that were potentially at risk for billing errors. They selected a stratified random sample for review of 154 paid claims with payments totaling $1,964,826. These 154 inpatient claims had payment dates in their audit period.

The OIG’s review found the hospital complied with Medicare billing requirements for 133 of the 154 inpatient claims reviewed. However, the hospital did not fully comply with Medicare billing requirements for the remaining 21 claims, resulting in net overpayments of $63,881 for the audit period. These errors occurred primarily because the hospital did not have adequate controls to prevent the incorrect billing of Medicare claims within the selected risk areas that contained errors. On the basis of their sample results, OIG estimated that the Hospital received overpayments of at least $273,346 for the audit period.

The hospital agreed with 10 of the 21 improperly billed claims but disagreed with the OIG’s findings of the other 11 claims. In the hospital’s response to the OIG, they created an appendix with detailed coding information and guidelines specifying the details with which they disagreed.

Taking a closer look at where they disagreed with the OIG can give your compliance program some insight on some of the details the OIG is reviewing.

For example, in the appendix created by the hospital, sample # B13 demonstrates one of the coding disagreements. According to this appendix, the OIG stated, "The pt BMI of 17.33 signifies slightly underweight. However, the hospital did not treat the pt for malnutrition. Malnutrition diagnosis not mentioned in the discharge summary. Recommend removing secondary dx 263 Malnutrition of moderate degree."

The hospital responded by stating they disagree with this OIG finding and support their own viewpoint with:

“Documentation of BMI 17.33, A Query was sent to the physician with the confirming diagnosis of Moderate Malnutrition. With this physician documentation, the BMI can be coded, as well as the Malnutrition.

* Reference: Coding Clinic 2Q 2000 pg. 17 -18 directs: If there is evidence of a diagnosis within the medical record, and the coder is uncertain whether it is a valid diagnosis because the documentation is incomplete, vague, or contradictory, it is the coder's responsibility to query the attending physician to determine if this diagnosis should be included in the final diagnostic statement. All diagnoses should be supported by physician documentation. Documentation is not limited to the face sheet, discharge summary, progress notes, history, and physical, or other report designed to capture diagnostic information. This advice refers only to inpatient coding.”

Sample # B32 is another example of disagreement.

The OIG finding included:

“The OIG recommend, "removing secondary Dx 556.9 Ulcerative colitis, unspecified. Medical records show the previous Hx of ulcerative colitis but no active problems/complications during the current inpatient stay due to this condition. The medical records stated that the carotid artery was caused by diabetes mellitus (DM) not ulcerative colitis."

The hospital disagreed by stating they felt the OIG was not following coding guidelines:

“* Supporting documentation: History and Physical and Consultation document the patient has Ulcerative Colitis, treated with Azulfidine 1,000mg three times a day.

* Reference: Coding Clinic 3Q 2007 pg. 13 directs: Chronic conditions such as, but not limited to, hypertension, Parkinson's disease, COPD, and diabetes mellitus are chronic systemic diseases that ordinarily should be coded even in the absence of documented intervention or further evaluation. Some chronic conditions affect the patient for the rest of his or her life and almost always require some form of continuous clinical evaluation or monitoring during hospitalization, and therefore should be coded.

* Reference: Per the Official Guidelines, Reporting of Additional Diagnoses directs: For reporting purposes the definition for "other diagnoses" is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring.”

These are just two examples where the hospital disagreed with the OIG findings. Though the hospital stated they will refund the money associated with the 10 claims upon which they agreed with the OIG, they are going to appeal these other 11 claims through their local Medicare Administrative Contractor.

Reviewing the details in the appendix provided in the hospital’s response to the OIG is a good way to see the kinds of claims the OIG is interested in when they are performing these compliance reviews.