OIG Auditing and Monitoring Guidelines for 2023 – Navigating New Changes

Conference Materials (Password Required)

Based on the Affordable Care Act of 2010 any physicians that treat Medicare or Medicaid beneficiaries will be required to have a compliance plan. Many offices are non-compliant and either do not have a plan, or have a plan but are not following it. The Office of the Inspector General (OIG) created an outline of a compliance plan for group practices that any practice can use as an outline to build a compliance plan. While this is an outline, there currently are no requirements that this has to be followed, but it is the best practice since the OIG oversees compliance. We will review the 7 effective components of a compliance plan released by the OIG, and discuss how to create your plan using this information. After the completion of a plan, it must be followed and executed. A plan not followed is worse than not having a plan at all. The compliance plan is always adjustable as long as all who must follow it are aware of changes that are made, and it really can be set up to meet the needs of any practice. The current basics of auditing will also be discussed.

Learning Objective:

• Understand the 7 components of a compliance plan
• Realize what areas of your office should be included in the compliance plan
• Build the compliance plan
• Learn how to apply the plan, and follow the steps
• Create compliance guidelines and goals that are obtainable
• Know what training materials will work best
• Confirm that the office understands the 2021 AMA E/M guidelines

Areas Covered in the Session:

• OIG
• CMS-CERT, RAC
• Cigna
• Humana
• Worker’s Compensation
• Affordable Care Act
• OIG Compliance Plans
• Plan Mandates
• 7 Effective Components
• Policies and Procedures
• Purpose of Auditing
• What to Audit
• Medical Necessity
• E/M Basics
• History
• Past, Family, Social, History
• Expanded Problem Focused History
• Detailed History
• Comprehensive History
• Examination
• Expanded Problem Focused Exam
• Detailed Examination
• Novatis 1997 E/M Score sheet’s
• Medical Decision Making
  • Diagnosis
  • Data
  • Risk
  • Treatment plan
  • Complexity of procedures/services needed
  • Risk of procedures/services needed
• Coding By Time
• Documentation Requirement
• Low MDM
• Moderate MDM
• High MDM
• Content of Counselling Summary
• Clinic/Outpatient Visits
  • New Patient Visits
  • Established Patient Visits
  • Clinic Consultations
• Hospital Inpatient Visits
  • Initial Hospital Care
  • Subsequent Hospital Care
  • Inpatient Consultations
• Documentation
  • E/M
  • Diagnostic tests
  • Order (medical necessity)
  • Hard copy
  • Interpretation
  • Procedures
  • Other Services
  • Signature
• Reporting Results
  • Document findings and keep as permanent records
  • Medical Records
  • Summary (see attachment)
  • Information shared with Provider(s)
  • Spreadsheet
• Audit Summary
• Post Audit Actions
  • Create protocol
  • Determine training means
  • Mandate Training
• Provider Training
• Follow Up

Suggested Attendees:

• Healthcare Executives CEOs, COOs, CFOs,
• Healthcare providers
• Hospital and facility administration
• Healthcare Policy Analysts
• Healthcare Business Researchers
• Legislative or Regulatory Advisors
• Billers
• Coders
• Administrators
• Managers
• Supervisors
• Physician
• Non-Physician providers
• Qualified Healthcare Professionals
• Compliance officers
• Consultants
• Claims adjusters
• Case Managers

Presenter Biography:

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This is a Live Virtual session.

A new way of immersive learning that allows you to engage live with our instructor and peers providing you with the flexibility to juggle the new work-life balance.

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