3 Ways to prevent an OIG audit

The Office of Inspector General (OIG) is prioritizing Medicare and Medicaid overpayments, leading to an increase in audits. Payers understand the risks to their financial statements, reputation and enrollment. The industry also has recent evidence of OIG’s intentions, including cases where Humana and Aetna, through a subsidiary, had to repay millions for alleged Medicare Advantage overpayments.  

At the same time, payers are already concerned about financial and operational challenges following the transition from Version 24 to Version 28. Health plans are pressured to manage flat or decreasing budgets while maintaining the accuracy of risk adjustment submissions to CMS.

Value-based care plans can be forgiven if they feel squeezed from both sides and are looking for solutions. Here are three strategies that payers can use to reduce their risk of OIG audits:

Proactive risk adjustment

Engage providers directly: The best way to prevent an OIG audit is to ensure that something is documented during a patient encounter. Engaging with and educating providers proactively reinforces the importance of capturing all relevant diagnoses during patient encounters. Accurate documentation provides lineage and provenance for risk adjustment submissions, reducing the likelihood of discrepancies that trigger audits.  

Target high-risk HCCs: Payers should also tap into analytics that identify high-risk HCCs (Hierarchical Condition Categories) more likely to attract the attention of auditors. Focusing on high-risk HCCs allows healthcare payers to allocate resources more effectively. A targeted approach creates time for a deep dive into how specific HCCs were coded and documented, increasing the chances of identifying and rectifying potential issues before they become audit findings.

Leverage clinical data interoperability: Reveleer’s Clinical Intelligence solution provides payers with a powerful tool for prospective risk adjustment. The platform integrates with provider EHR systems and utilizes a nationwide network of clinical data to identify potential diagnosis gaps. The platform alerts providers of potential missed diagnoses at the point of care through real-time data analysis. Reveleer goes a step further by delivering a compendium of suspected diagnoses and supporting clinical evidence directly into the patient's chart within the provider's EHR system. This proactive approach empowers providers to capture complete documentation during encounters, ensuring accurate risk adjustment submissions and reducing the likelihood of audits. In one example, an ACO used the Reveleer platform to surface undiagnosed conditions realizing a .13% RAF uplift opportunity.

Streamlined retrieval and coding

Automate chart intake and processing: Manual medical record retrieval processes are time-consuming and prone to errors, increasing the risk of audit findings. Reveleer addresses this challenge by automating chart intake and processing using optical character recognition (OCR) technology, capable of processing 96,000 pages per hour. Rapid data extraction transforms raw data into actionable insights, enabling efficient coding and analysis.

Prioritize value-per-chart: Payers should focus on reviewing charts with the greatest potential to impact risk or quality scores. Reveleer's AI-powered Evidence Validation Engine (EVE™) helps abstractors to prioritize by eliminating "zero-value" charts, allowing coders to concentrate their efforts on high-value charts. Intelligent automation directs coding effort where it matters most.

Integrated retrieval methods: Reveleer offers a comprehensive suite of digital and traditional retrieval methods, providing flexibility and adaptability to diverse healthcare environments. The platform integrates with EHR systems, facilitates bulk uploads, offers a secure provider portal, and connects with third-party vendors. An integrated approach streamlines retrieval processes, regardless of the provider's technological capabilities.

Comprehensive quality assurance

Mock audits: Mock audits can identify potential problem areas and improve compliance. OIG provides a toolkit for mock audits that cover every HCC and ensure that risk adjustment documentation and coding is sufficiently scrutinized.

Overread: A clinical overread process drives accuracy, compliance, and collaboration across coding staff. Reveleer integrates a collaborative overread process into its platform, minimizing coding errors and reinforcing regulatory standards. Overread programs designed to focus on specific, high-risk HCCs and quality measures further mitigate audit risk. Reviewing and validating coding through a multi-layered approach significantly reduces the chance for discrepancies.

Real-time management: Preventing errors requires real-time data. Technology embedded into the treatment workflow can support providers by ensuring documentation is created at the time of the encounter and properly supports downstream risk adjustment after the fact. A proactive approach ensures that documentation practices align with regulatory requirements, making them less likely to trigger an audit.

Increased scrutiny from the OIG underscores the importance of accurate risk adjustment submissions, and proactive measures are essential for navigating this evolving landscape. By implementing these strategies, payers can better protect their reputation and financial stability through regulatory compliance.

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