Industry experts believe there will be an increase in audits over the next year, following a slower audit period during the height of the COVID-19 pandemic. Audits similar to the ones conducted by unified program integrity contractors (UPICs) hired by the U.S. Centers for Medicare & Medicaid Services (CMS) have gained momentum in home health this year, which are used to investigate potential fraud. This may have been due to less stringent COVID-19 restrictions. Having said that, the periods when COVID was an issue are expected to be the focus of further audits, which is something home health agencies will have to address.
For instance, audits by the U.S. Department of Health & Human Services’ Office of Inspector General (HHS-OIG) are also expected to proliferate, with focus on provider relief funds.
Expect the Unexpected
HHS-OIG audits can catch home health agencies by surprise, but the key to getting through any battle is having the right tools and headspace. Expect that the audit will happen and prepare for it as early as possible. This could mean the difference in achieving a successful audit process.
Things to Remember
Currently, there is a lack of understanding by the general public and home health providers of the OIG audit process. To be one step ahead means knowing what the OIG or other federal agencies look for when auditing. Here are important and notable factors to keep in mind:
- The routine “Work Plan” audits from the OIG are not targeted audits.
- Audits target all home health services in general, and the OIG includes 100 claims at random, evaluates them, and then comes up with an error rate. OIG will extrapolate the error rate and assess it over the industry.
- Both UPIC and OIG audit processes will look at financial data for home health agencies, homebound statuses, OASIS compliance, and other factors that impact payment.
Considering the pandemic’s shifting landscape, the OIG will likely refine its audit process, which will be clearly defined later than sooner. However, it is important to keep in mind that the fundamentals of what they look into are still present and that they are in the process of being more precise with their requirements.
Tips for Being Audit-Ready
Below are some practical tips that agencies can apply to be prepared for audits:
- Ensure that all staff are familiar with the latest information about internal processes for handling an audit request.
- Establish an efficient audit response infrastructure by assigning specific roles that will respectively deal with certain requests.
- Ensure that staff knows the internal processes for handling an OIG audit request.
- Do internal reviews on policies and procedures, which should mirror and support your agency’s internal processes.
- Keep up with the compliance program by focusing on documentation.
One surefire way to be ready for an outsider like the government is to firm up your agency’s internal systems by having a healthy and robust compliance program.
A proactive approach to being continually prepared is to improve your clinicians’ knowledge and skills by providing them with ongoing reeducation through training and the like. It is best practice to maintain quality and accuracy in documentation, rather than being adept in catching errors thereafter.
Clinician reeducation is effective, but also time-consuming. It is important to tap help from your quality program to support this plan to improve your clinicians’ patient care and documentation skills in the long run.
Furthermore, your QA provider should utilize tools for reporting and feedback mechanisms. This includes monitoring clinician progress, identifying areas for improvement, and reporting other insights. These will enable your agency to address the challenges immediately to keep your entire documentation audit-ready.