Background on OIG Guidance Documents
The Office of Inspector General has published voluntary compliance program guidance documents for various healthcare sectors, including hospitals. While voluntary, these documents represent the government's expectations and are frequently referenced during investigations and settlement negotiations, making them essential reading for RHIA candidates.
Risk Areas Identified for Hospitals
- Billing for items or services not actually rendered
- Submitting claims for equipment, medical supplies, and services that are not reasonable and necessary
- Double billing resulting in duplicate payment
- Providing medically unnecessary services
- DRG creep and upcoding of diagnoses or procedures
- Outpatient services rendered in connection with inpatient stays
- Knowing failure to provide covered services or necessary care to Medicare or Medicaid beneficiaries
The Seven Elements Applied to Hospitals
The OIG hospital guidance reinforces the same seven elements found across its industry-specific guidance: written standards, a compliance officer and committee, education and training, effective lines of communication, auditing and monitoring, enforcement through well-publicized disciplinary standards, and prompt corrective action. The hospital-specific guidance adds emphasis on coding and billing accuracy given the complexity of hospital reimbursement systems.
Focus on Coding and Documentation
Because DRG-based reimbursement creates financial incentive concerns, the OIG guidance places particular emphasis on the integrity of clinical documentation and coding processes. HIM professionals are central to this risk area because they oversee coding accuracy, clinical documentation improvement programs, and the audit processes that detect upcoding or unbundling.
Self-Disclosure Protocol
The guidance encourages hospitals to use the OIG Self-Disclosure Protocol when they identify potential fraud, allowing organizations to resolve liability under more favorable terms than if the government discovers the issue independently. RHIA candidates should understand that voluntary self-disclosure is viewed favorably as evidence of an effective compliance culture.
Practical Application
- Coding compliance audits should be scheduled regularly and cover both inpatient and outpatient coding
- Clinical documentation improvement queries must be non-leading and clinically supported to avoid compliance risk
- Chargemaster reviews should be part of the annual compliance audit calendar
- Findings from audits should feed into training programs to close identified gaps
Key Takeaway
The OIG hospital guidance is a foundational compliance document that ties directly into everyday HIM functions like coding accuracy, documentation integrity, and audit program design, making it a high-value study topic for the RHIA exam.