PPS Alert for Long-Term Care
Editor’s note: This month’s “PPS Q&A” was written by Wayne van Halem, AHFI, CFE, president of The van Halem
Group, LLC, a Medicare consulting and auditing firm in At- lanta. o submit a question for upcoming issues, e-mail Associ- ate Editor MacKenzie Kimball at email@example.com.
We conducted an internal audit of our facility and found some billing errors. Now what do we do?
First, let me congratulate you on taking the initia- tive to conduct a proactive internal audit; it is a fa- cility’s best defense when it comes to compliance in billing practices.
In fact, conducting internal audits is one of the seven elements recommended by the Office of Inspector Gen- eral (OIG) as part of an effective compliance program. Another recommended element is developing corrective action initiatives.
If an internal audit identifies a billing error, your facil- ity should take the following steps:
1. Determine the resulting effect of the error. For example, were a substantial number of incorrect claims submitted to Medicare or Medicaid as a result of the er- ror? Or was it an isolated incident? You may need to conduct additional audits to determine the overall effect of the error.
http://oig.hhs.gov/fraud/selfdisclosure.asp, was designed on the premise that providers must take an active role in protecting government funds and resolving issues. If it is determined that intentional fraud was committed, follow- ing this protocol does not protect you from actions taken by the federal government. But for billing errors and mis- takes, this protocol provides you with a procedure to fol-
low to refund the money.
2. Determine the root cause of the problem. In some instances, a particular employee may be respon- sible for the error, or a problem with an internal policy
or billing system could be the cause. Once the cause is identified, it must be corrected. If an employee was at fault, determine whether the situation warrants disci- plinary action or additional training. If there was a glitch in your billing software, contact the system administrator and have it fixed. If a policy is missing a crucial step, you
should revise that policy.
3. Implement a correction action plan (CAP). Simply put, a CAP is designed to demonstrate that you
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Illustration by David Harbaugh
If the error resulted in a loss to a government or pri- vate insurance program, you must refund any monies. If the error was an isolated incident that resulted in a small number of incorrect claims with a minimal nominal value, you can contact your fiscal intermediary, Medicare ad-
ministrative contractor, or claims administrator to inform them of the error and request that the claims be adjusted accordingly.
If the error is more widespread, resulting in a con-
siderable overpayment, or was a result of a potentially
fraudulent practice, I would recommend following the
self-disclosure protocol outlined by the OIG. This pro- tocol, which can be found on the OIG’s Web site at
“Our areas of decline just preempted our areas of improvement. An unannounced survey team just arrived.”
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