A recent OIG audit found that Medicare improperly paid an estimated $15.2 million for SI joint injections. CJ Wolf examines the coverage, billing, medical necessity, and documentation failures behind the findings and identifies three actions healthcare compliance teams can take to reduce risk.
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A compliance control can be documented, automated and still fail to manage risk consistently. An HHS-OIG audit offers a practical example of why healthcare organizations need to look beyond whether controls exist and verify that they actually work.
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Compliance risks associated with medical necessity happen when providers fail to show clinical evidence that a service is essential for a patient’s health. This often leads to legal, financial and operational consequences.
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When a new regulation or update is enacted, the clock starts ticking toward its inevitable effective date and another compliance deadline. Regulatory change management is a moving target with constant deadlines and uncertain task status.
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This is the first article in a series on medical necessity — an area that many compliance programs struggle with. In this piece, we explain the medical necessity compliance risk in general, while subsequent articles highlight specific examples of enforcement actions experienced by medical providers such as hospitals and health systems.
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The overwhelming pace and complexity of healthcare regulatory change have become so routine that the constant grind now poses a distinct risk to the organization it’s intended to protect.
Yet, many hospitals still treat regulatory change as a routine monitoring activity, failing to adopt the systems thinking and discipline necessary to truly mitigate the risk.
This article by a top healthcare compliance expert explains what it takes to make that transformation. (She also explains what spinach has in common with compliance risk assessment.)
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Just this week, I was in a colleague’s office. Literally, it looked like Staples puked up aisle 3. I asked her what everything was, because you couldn’t make heads or tails of any of it. She explained that it was patient records that she didn’t know what to do with.
I asked her, “Well, what does the process say to do?”
“Process?” she said. Nice girl, means well, greener than a pepper tree.
After helping her re-organize everything, I was motivated to put together some ideas to help others in her situation. Here are some record retention best practices in the event you have hoarded up some claptrap and now have to figure out what to do with it.
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Many compliance professionals rely on HHS OIG focus areas as they perform risk assessments and plan subsequent auditing and monitoring activities. In November 2024, the OIG added an item to their Work Plan describing their intention to review Medicare Part B payments for skin substitutes.
This blog explores the implications for compliance and what health systems need to be aware of.
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A good healthcare compliance program is all about reducing risk, both in patient care and in financial reimbursement. This detailed blog by compliance expert, CJ Wolf, will bring you up to date on the compliance risks associated with certain anesthesia services.
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