An OIG inspector just walked through your door; what do you do next?
States will be more involved in future audits
The words, "Hello, I’m from the Office of the Inspector General," are enough to keep any HIM professional awake all night. Even when your HIM department is run by the book and documentation is thorough and accurate, there remain the nagging doubts that something could be wrong and the OIG inspector will find it.
Rather than wait for the OIG to show up and raise the anxiety level in the office, there are practical measures the HIM department can take to both prepare for an audit and prevent problems.
"If you’re on your toes and are familiar with what’s going on in the industry, then you’ll know what they’re looking for," says Nadinia Davis, MBA, CIA, CPA, RHIA, assistant professor of health information management at Kean University in Union, NJ. Davis is a certified internal auditor, whose background in accounting and experience working in the financial services industry has helped her develop a thorough understanding of the auditing process.
It will do no good to become complacent and hope your facility will not be audited by the OIG, because two trends likely will make that audit a reality, Davis notes.
First, the OIG’s own compliance suggestion plan recommends routine operational audits; second, the OIG has begun to partner with state governments to conduct audits, and these likely will increase, she says.
So here are some strategies that HIM professionals can employ to prepare for an OIG audit — and to handle an audit once the auditor walks through the door:
1. Channel your energies into responding precisely to the auditor’s requests.
An auditor may ask for all of the documentation about every pneumonia case a facility has handled. This may not mean the auditor wants a printout with every upper respiratory code on it. What is likely meant is that the auditor wants to look for examples of pneumonia upcoding, so an HIM professional should pull the documentation that applies only to pneumonia codes.
Typically, the OIG knows prior to assigning an audit exactly what an organization has billed and coded and has found some pattern that is out of the ordinary. So the OIG auditor will be trying to target specific items and generally is not doing a random audit, Davis says.
For instance, if the auditor asks for pneumonia cases, this means the auditor believes there are cases that were coded for bacterial pneumonia although the physician has not documented evidence of pneumonia.
The OIG might call this upcoding, while the doctor believes the patient had bacterial pneumonia based on the sinus symptoms. Or it could be an instance when the doctor did send out samples for testing, and the results returned after the coder already had recorded the bacterial pneumonia code. This type of problem could be prevented through an internal audit prior to the OIG visit.
Avoid off-hand remarks to auditor
Also, the audit’s findings in this example would be limited to the pneumonia coding problems, unless HIM staff volunteer additional information to the auditor.
"Answer the questions they ask and don’t say anything more," Davis says. "A lot of times a seasoned auditor can make a lot of assessments from off-hand remarks, which is why disgruntled employees are a nightmare in an audit situation because they blab away about a lot of stuff that has nothing to do with the audit."
This type of problem can lead to a full-blown audit when the OIG auditor merely intended to conduct a cursory check of the facility’s records, Davis adds.
2. Document your internal auditing efforts.
"Auditors don’t know your job; they don’t know your business or what’s going on in your department or what your internal auditing plan is," Davis says. For this reason, HIM departments need to document their internal auditing efforts so a professional auditor can see exactly what the department is doing along these lines. Plus, the documentation will offer validity and possibly ameliorate any negative findings that come to light, Davis explains.
For instance, suppose an OIG auditor reviews files from 1996 to 1998 and finds instances of upcoding, which means the facility will owe money to Medicare. This might lead to a broader investigation and more problems. However, if the department has been conducting its own audits and can prove this to the OIG, then perhaps the findings will be limited to those particular incidents, Davis says.
"You tell the auditor that in the past six months you’ve been reading about what the OIG has been doing and have audited your own staff very carefully, and here are the steps you’ve taken," Davis says. "Here are the steps you’ve taken, and you just haven’t gone that far back yet."
This type of response will work, she says. "Every person I have spoken to who has said they did work for the OIG has said that when you are demonstrating your compliance, and coming forward with information, and making corrections, it goes a lot easier on you," she says.
"And that’s not just the OIG, but true with other payers too," Davis adds.
It’s also important for HIM departments to learn how to document well, which is similar to the performance-improvement process a facility might use to achieve accreditation.
"What a department needs to do is say, We’re going to do coding-quality audits, and we’re going to look at our charts and data and see if we can spot any wacky trends, any patterns that look odd, and then we’ll do random coding audits of all coders to make sure coding is at an appropriate level,’" Davis advises. "You need to do a good sample of every chart and quarter, and you can go through it and have either your supervisor look at the charts on a routine basis or make the case to management that you need to spend a little money on a consultant now."
3. Be proactive about mistakes.
There may be advice from some quarters that it’s better not to do internal audits because if something is found then it can be used against the facility, Davis says.
"The exact opposite is true," Davis says. "If you do these audits and then do something about what you find, then you won’t have an audit in the first place."
When a facility receives compliance advice from a lawyer, it’s a good idea to make certain the attorney is experienced in the health care field, because some of the advice applied to other areas is not true in this field, Davis cautions.
Facilities that audit their records and fix mistakes also have the opportunity to educate and train staff to prevent future mistakes, and all of these efforts should be documented, Davis says.
Occasionally, there will be instances in which a HIM professional audits records, finds mistakes, and reports these to the facility’s management, who then do nothing about it. This is a difficult situation, but it shouldn’t prevent the HIM professional from doing what’s right, Davis says.
"If you know stuff is going on, and you can’t get your organization to fix it, then document what you said and leave the job," Davis advises. "Find another job, because why should you place yourself at risk for becoming a scapegoat when the organization is audited?"
4. Don’t rely on private-payer audits to find your mistakes.
There’s a tendency among some organizations to pass on the internal audit and instead wait to see what private payers say in their audits of files. This is a mistake, Davis says.
"They’re relying on external auditors to tell them what’s wrong, and I don’t think that’s appropriate, because the only thing Blue Cross is auditing is their own charges. These people are doing audits only of their own stuff, and they’re arguing reimbursements on a case-by-case basis, and that’s not research," she adds.
Also, OIG audits aren’t the only government audits for which an organization should be prepared, Davis warns.
Confidentiality issues will be the subject of future audits as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), she notes.
"You have to look at all areas of exposure, including privacy issues and how the department stands between the outside world and patient records," Davis says. "Understand HIPAA regulations, and don’t wait for someone to tell you what to do."
5. Take care of the details and remain calm.
Look at the documentation times that will have an impact on payment, and make certain the charts are in terminal digit order and are filed correctly, Davis says.
"Also make sure you have the support system within your organization to address the findings you might have, and that’s where multidisciplinary issues come in," Davis says. "HIM professionals need to be on board by either leading the charge or participating in whatever activities are going on."
OIG auditors — who may be lawyers, former hospital administrators, or accountants — know the language of auditing and are familiar with HIM professionals’ work. So dealing with an auditor can be intimidating.
"Everyone I know who’s had an OIG audit said it was a total surprise," Davis says. "I’ve heard stories of people who had agents come to their home, and they make it more nerve-wracking than it needs to be because they don’t want you to do anything before they get there."
This is why HIM professionals must remain calm, call their supervisor if they are permitted to do so, and obtain corporate counsel as soon as possible, Davis says.
"They may not let you make these telephone calls, so you should check the auditor’s identification and documentation, and then make the calls as soon as you can," she adds.
Also, staff need to be trained on an ongoing basis not to speak with auditors. If an employee greets an auditor, the employee should refer the auditor to the director of the department so all information is filtered through a central person.
"When I was an auditor, I always wanted access to the staff because that’s where I got all of my information," Davis says.
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