Medicare Compliance & Reimbursement

Question: One of our three outpatient practices has missed our 95 percent coding accuracy target for two consecutive quarters. After education, its accuracy improved to 89 percent from 82 percent, but follow-up audits still show unsupported evaluation and management (E/M) levels and inconsistent modifier use. Should I report this to the governing board, or is it enough to keep the issue with the compliance committee?

Oregon Subscriber

Answer: You should report it to both, but tailor the level of detail included. The compliance committee should have an operational-level understanding of what’s going on in order to manage the corrective action plan, while the board should receive a concise summary because the repeated failure may create repayment, audit, and enforcement risk.

When you’re compiling a report for the committee, include details about the audit sample, error types, estimated claim impact, root cause, responsible leader, corrective steps, deadlines, and retesting plan. Determine whether affected claims require a broader review or refunds, and include that information in the report. Compare the practice with the other two locations using the same methodology so the committee can determine whether the issue is an isolated workflow problem or presents an organization-wide risk.

The board report should state that one practice remained below the 95 percent target for two quarters, improved to 89 percent from 82 percent after education, and continues to show unsupported service levels and modifier errors. Summarize the potential financial exposure, whether refunds are underway, the remediation deadline, and when effectiveness will be retested. Avoid patient identifiers, reporter identities, and unnecessary investigation detail, but identify any resources or management action needed from the board.

This risk-focused reporting approach follows Office of Inspector General (OIG)’s Practical Guidance for Health Care Governing Boards on Compliance Oversight, which recommends that boards receive department-specific reports identifying compliance risks, strategies for addressing those risks, and the results of mitigation efforts.

Follow your organization’s written escalation policy — you may want to submit the report sooner than the regular schedule if your review identifies a significant overpayment, credible evidence of intentional misconduct, interference with the audit, retaliation, refusal to implement corrective action, or a rapidly increasing pattern of unsupported claims. OIG’s General Compliance Program Guidance recommends that the compliance officer report either to the CEO, as long as you have direct and independent access to the board, or directly to the board.

After you deliver the reports, document what both the committee and board reviewed, questions asked, decisions made, deadlines, and evidence that corrective action was validated.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC