Data Advantage Medicare Coding Alert

Report Description and Definitions
The Office of the Inspector General (along with the FBI) has become increasingly aggressive in pursuing actions under the False Claims Act. The impact on hospitals and their managements can be devastating.  The OIG’s aggressive stance is unlikely to go away anytime soon given their escalating yearly goals for the recovery of misspent dollars.

Inspector General’s Goals for Recovery of Medicare Dollars
To accomplish their goals, the OIG has rapidly accelerated the number of Corporate Integrity Agreements being executed between itself and hospitals. Despite its rather attractive name, a Corporate Integrity Agreement is anything but endearing. Specifically, it is a global settlement of an OIG fraud investigation.  Under it, the hospital not only pays up to treble damages - - it also agrees to submit to performance monitoring with OIG involvement for the next 3 to 5 years.  This includes the submission of formal written reports annually and mandatory training.

The importance of this acceleration should not be lost on any person who bears ultimate fiduciary responsibility for a health care institution.  To assess your vulnerability to this threat, it is now more important than ever before that you know your data. Additionally, knowing your data relative to your peers is critical. Much like IRS audits, performance out of the "norm" becomes an obvious target for investigation by government authorities.

The Data Advantage Medicare Coding Alert™, which is published by individual state:

• Covers 10 selected DRG pairings and 1 "triad" most susceptible to current and future OIG scrutiny
• Includes rankings listing all hospitals in your state for each DRG pairing
• Includes national and local benchmarks for comparisons - state, MSA, bed size, geographic, etc.
• Also shows all paired DRGs (with/without CC) compared to national averages
• Shows all of this information over the past 3 years so you can see questionable trends

With this information, you can easily document for yourself and your senior managers your potential exposure to this focal area for OIG inspectors. The clear fact is any performance out of the norm will likely be addressed by the OIG. If you face a problem, being able to identify it now and beginning corrective action may substantially reduce your personal and corporate risk.

Source of Data

Medicare Provider Analysis and Review File (MedPar File)
This report includes records for 100 percent of Medicare beneficiaries using short term acute care hospital inpatient services for the most recent year. The records are extracted from the actual bills submitted for payment to Medicare by the provider. All Diagnostic Related Groups (DRG) listed are those assigned by HCFA to the patient record when he/she was discharged from the facility. Records with various anomalies identified by proprietary computer programming have been excluded to make the comparisons as accurate as possible; this includes records for patients in which Medicare was not the primary payor.

Hospital Cost Report Information System
This report has included information from the Hospital Cost Report Information System (HCRIS) file which contains cost and charge data extracted from the Medicare Cost Report (Form HCFA 2552-92/96). If a hospital did not have a valid or current cost report on the file, the data needed to compute the cost of treatment was not available and the cost information was excluded from the report.

*To view a sample of this report in your web browser click here.