By Margaret Scavotto, JD, CHC
Director of Compliance Services
Management Performance Associates
The OIG recently issued a report summarizing HHS’ improper payment rates in Fiscal Year 2015. The report found a 12.09% improper payment rate for Medicare fee-for-service claims in FY2015. HHS pointed to two main causes of the improper payments:
1) insufficient documentation, and
2) medical necessity errors
SNFs and home health agencies were two of the biggest offenders for insufficient documentation. For example, SNFs submitted claims for skilled services, without obtaining a certification.
Compliance Is Your Defense
The OIG now recommends that HHS “focus on the root causes for the improper error rate percentage and evaluate critical and feasible action steps to decrease the improper error rate percentage below 10 percent.” Now that HHS has marching orders from the OIG to get its error rate down, providers can expect to see more claims audits, with a focus on medical necessity and documentation. Providers should make sure their compliance auditing plans include regular reviews of claims for medical necessity, and sufficiency of documentation. The bottom line: Find documentation gaps before they become a repayment.
Poor Documentation Affects Quality, Too.
Sloppy documentation practices don’t just result in false claims. They can impact patient care, too. A Minnesota nursing home resident recently died after a transcription error on her medication order. The resident, who had a history of stroke, had an order for the anticoagulant warfarin. The LPN responsible for transcribing the order placed the order on another resident’s chart. After 9 days without warfarin, the resident suffered a stroke and died. The nursing home allegedly did not monitor nurse performance and did not evaluate nurses’ medication aptitude.
How Will You Find Your Weakest Link?
In a health care provider, nobody’s perfect, and everyone is very busy. Nursing staff need ongoing training about proper documentation. Likewise, medical records need continual double-checking and auditing to identify errors and gaps in documentation practice. The bottom line: Use regular compliance training and audits to find documentation gaps before they become a tragedy.
With OIG and CMS scrutiny of provider claims at an all-time high, now is a great time to assess your compliance program and find your weakest links.
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