“Finally Friday!” Fighting Subjectivity in OIG Audits

FRIDAY March 17, 2017:

Fighting Subjectivity in OIG Audits

Standing Your Ground versus Fuzzy Logic

X = Deny or Approve, depending on who you are…

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THIS WEEK we are privileged to be able to look inside a recent case where the OIG took aim at a provider over their interpretation of the use of two diagnosis codes, 261 (Nutritional marasmus) and 262 (Other severe protein-calorie malnutrition)

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Dr. Melinda Battaile was one of two Physician Advisors fighting back against the “fuzzy logic” used by OIG Auditors.

Joining our panel is one of the physician advisors who was a member of the team of professionals tasked with fighting an OIG report that claimed their system had incorrectly billed Medicare for Inpatient claims citing Severe Malnutrition.

The OIG claimed that “the Hospital used diagnosis code 261 or 262 when it should have used codes for other forms of malnutrition or no malnutrition diagnosis code at all… [concluding that based upon their] sample results, the Hospital received overpayments of at least $1,403,132 for the audit period.”

Of course, as you might suspect already, all of this was based upon the OIG’s interpretation of the documentation for those diagnoses, and as I understand it, not a lack of documentation.

Vidant disagreed wholeheartedly – go figure – and we are privileged to have joining us, Melinda Battaile, MD  FHM  MMCi, Physician Advisor, Clinical Documentation Advisor Program, from Vidant Health.

You might want to download and go over the OIG report before the show, and compose your questions for us and Melinda before the show.

(If you’d like a primer on Fuzzy Logic, see slides 12, 30, 31 & 32 in this presentation.)

ANYWAY… the question for us this week is:

HOW do you prepare for these kind of audits, especially where vague ICD-9 codes are involved, and the OIG is using fuzzy logic?

Be SURE to join us when our Panelists will be discussing :

  • WHY did the OIG single out Vidant Health?
  • WHAT was Vidant doing to prevent these denials?
  • WHAT kind of references were used to defend the coding?
  • WHAT were the credentials of the OIG Auditors?
  • WHAT were the “categories” of fault claimed by the OIG?
  • WHAT were the most illogical denial reasons given by the OIG?

So join us, share your own insights and bring your questions for us!

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OIG Report 31500011 473.31 KB 59 downloads


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