In this episode, Kristen Eglintine, BESLER’s Coding Manager of Revenue Integrity Services provides us with a glimpse into our next webinar, OIG Workplan Summary, that will be presented live on Wednesday, May 15th, at 1 PM E.T.
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Learn how to listen to The Hospital Finance Podcast® on your mobile device.Highlights of this episode include:
- Overview of OIG
- Why the work plan important to us in healthcare
- The various projects that the agency plans to investigate
- Advice for CDI and coders based on the OIG audits
Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome back Kristen Eglintine, BESLER’s Coding Manager of Revenue Integrity Services. In this episode, Kristen will provide us with a glimpse into our next webinar, OIG Workplan Summary, that we’re presenting live on Wednesday, May 15th, at 1 PM Eastern Time. Welcome back and thank you for joining us, Kristen.
Kristen Eglintine: Thank you. I’m very excited to be back. It’s been a little while, so I appreciate this and look forward to talking with you.
Kelly: Yes, it has been a bit. Well, let’s go ahead and jump in. So, you’re presenting on the OIG Workplan Summary webinar very soon. Can you begin by giving us a quick overview of the OIG?
Kristen: Absolutely. Again, thank you for having me back. And thanks to all of you out there who are listening and spending a few minutes with us today. We all have heard of the OIG. The OIG is the Office of Inspector General. It’s a Department of Health and Human Services and was established in 1976. It’s a large government department. There are about 1,700 employees, and it has been at the forefront of the nation’s effort to fight waste, fight fraud and abuse while trying to improve the efficiencies of Medicare and Medicaid, and more than 100 other departments of the Health and Human Services. OIG’s official mission is to provide objective oversight to promote the economy, efficiency, effectiveness, and integrity of the HSS programs, as well as the health and welfare of the people they serve.
Kelly: Thank you for that overview. Why is their work plan important to us in healthcare?
Kristen: Oh, great question. So, for this year, in 2024, the OIG has issued a one-year work plan with various projects in this plan. The work plan is important to all of us in healthcare, as the outcomes affect and then ultimately change the healthcare system as we know it. The majority of the agency’s resources go towards the oversight of Medicare and Medicaid, which are programs that represent a significant part of the federal budget, and then that affects this country’s most vulnerable citizens, like the elderly, the poor, the disabled. If we look back at last year, so for 2023, 77% of the resources went to Medicare and Medicaid programs, with only 23% going to public health, science and regulatory agencies, human service agencies, and health insurance marketplaces. So, with that 77% of their resources focused on Medicare and Medicaid programs, there’s no doubt their findings affect Medicare and Medicaid payments. Together, these two health insurance plans covered over 160 million people in 2023. So however we slice it, their work is important to us as citizens and to the healthcare industry as a whole.
Kelly: Wow, that’s very interesting. The OIG work plan establishes various projects that the agency plans to investigate in the coming year. Are there specific areas you will focus on?
Kristen: Yes. We will break the webinar down into three segments, current, past, and transfer. So, for the current and past projects, we’re going to focus on coding and documentation. March 15th of this year, the OIG updated their work plan with eight new items. We will dive into one of the eight items, and I think hospitals will find this interesting. The OIG is conducting a study on Medicare inpatient hospital billing for sepsis. So, let’s talk about sepsis just for a moment here. So, we’ve all heard about sepsis; we know what it is. But just as a refresher, it’s a life-threatening condition. It occurs when the body responds severely to an infection. It requires early intervention for the best outcomes. The definition of sepsis has changed over the years in an attempt to identify it more accurately. So, because of this evolving definition, hospitals and coders and physicians, insurance companies, and CMS, they all may recognize and/or use a different version. So currently, the challenge is between sepsis-2 and sepsis-3.
Sepsis is the number one cost of hospitalizations in the US, and it consumes more than $27 billion each year. So, because of the economics of sepsis and the seriousness of the condition, it’s no surprise the OIG has added a sepsis audit to their work plan for this coming year. The OIG will estimate the costs to Medicare associated with using the broader, rather than the narrower, definition of sepsis. So again, it’s the sepsis-2 versus a sepsis-3. The past project I will go over is a Medicare Advantage audit on HCC payments. A final report with findings has been issued for this audit, so we will look at it in detail and go over the findings. The findings will impact how Medicare Advantage Plans report HCCs to CMS going forward, as the OIG found significantly inaccurate reporting of HCCs. So, for Medicare Advantage plans to report HCCs correctly, documentation and coding must be accurate, making this audit very relative to a lot of us in healthcare. So let me give you just a quick example. Acute conditions map to higher HCCs, but for that acute period only. So if you’re having an acute MI or you’re having a heart attack, it’s acute while it’s happening, but it’s not always acute.
Hopefully you recover and then once symptoms resolve, you’d have an old MI, not an acute MI. So, the documentation would have to be specific to say, now, it’s an old MI. And it would be coded as such rather than an acute MI, therefore paying less. And this makes sense because having an old MI, something in the past, would go to a lesser HCC, as it does not require the resources that having an acute heart attack at that moment would.
Kelly: That’s very interesting. So do you have any advice for CDI or coders based on these OIG audits?
Kristen: It’s important to pay special attention to the high-risk diagnoses that the OIG stated in its report. So, we just talked about one example, the acute MI, but there are six more. Additional coder training specific to these conditions may be necessary and helpful. HIM internal reviews should be added if they are not currently done. Health plans should add an extra layer of validation to their risk adjustment programs. Just confirming acute conditions, whether they are acute or have moved to chronic or do they moved to history of, something that simple can make such a big difference. Regarding the inpatient sepsis billing audit, while it’s not scheduled to be completed until 2025, in the meantime, there’s a lot of things we can do. It’s important to have good documentation practices in place. A few examples are physicians should link any organ dysfunction to the diagnosis of sepsis, list the infection site causing sepsis, or link the infection if it’s due to a device such as a UTI or a catheter. Linking positive cultures to the infection helps, such as a Pseudomonas pneumonia. And then finally, clearly document if a patient has been put on a sepsis protocol and what clinical indicators they have.
Kelly: We appreciate that advice. Thank you. And so, Kristen, is there anything else you want to tell us about the OIG work plan?
Kristen: So, the recent addition of the hospital’s inpatient billing audit of sepsis is exciting. So, from a coding perspective, I have personally been involved in inpatient DRG audits where the presence of sepsis is debated. And if so, was it documented correctly? And if so, was it coded correctly? So, I personally am really looking forward to having more guidance on such a serious and prevalent medical condition. As a final thought, and to follow up on the third segment of the webinar, I would just like to mention that Mary Devine, BESLER’s VP of Revenue Integrity, is going to talk about the items associated with Transfer DRG, which are Medicare Hospital payments for claims involving acute and post-acute transfer policies. In the last few minutes, I just skimmed the surface of what Mary and I will talk about on our upcoming webinar. So, I invite everyone to attend to learn more about the OIG work plan and how hospitals’ bottom lines can benefit from their audits and from their work. The OIG Workplan Summary Webinar will be on Wednesday, May 15th, at 1 PM Eastern Time. Thank you for listening today. Thank you for having me, Kelly, and I wish everyone a great day.
Kelly: Well, thanks so much, Kristen. We really appreciate this sneak peek into that upcoming webinar that you mentioned, the OIG Workplan Summary. That, again, is going to be live on May 15th at 1 PM Eastern Time. Thanks again, Kristen, and thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…
[music] This concludes today’s episode of the Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.com/podcasts. The Hospital Finance Podcast is a production of BESLER | SMART ABOUT REVENUE, TENACIOUS ABOUT RESULTS.
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