Over the past six months, in our own client work and published settlements, it is evident that the Department of Justice (“DOJ”) is continuing to focus its audit efforts on patient status.  Most recently, a Houston-based health system agreed to pay $1.9 million to resolve allegations that three of its hospitals improperly billed Medicare for inpatient services that the DOJ deemed should have been billed as outpatient care. In our Revenue Integrity Audit work, we are seeing more probes into patient status and medical necessity denials in this area.

As budgets tighten and the pressure increases from the government, healthcare organizations need to proactively ensure the compliance of their coding and documentation. What steps can you take?

• Conduct Pre-Bill Revenue Compliance Audits – Identify current opportunities in code assignment and documentation practices, resource performance and capacity, reimbursement opportunities, and mitigate denials.
• Assess Clinical Documentation – Determine education opportunities for providers and develop efficient and effective communication methods between Clinical Documentation Improvement (CDI) and Health Information Management Staff and providers. High functioning CDI programs both inpatient and outpatient are essential.
• Educate – Mitigate denials, improve documentation and make staff more effective through continuous education!