March 2000

Health Care E-lert - Compliance Update, 03/10/00

3 min

A few weeks ago in an E-LERT, we advised our readers that, since your compliance plans have now been in effect for a reasonable period of time it might be a good idea to assess compliance with your compliance plan, i.e., to review your plan to see if you are carrying out the responsibilities you undertook in the plan.

Going a step beyond that, one of the elements of your plan should be to keep apprised of new compliance issues and to check within your own organization to see if those issues might be present. A good way to do this is to periodically review the excellent website maintained by the Office of the Inspector General of HCFA ( for alerts and releases relating to what the OIG views as areas of compliance concern.

A recent item on the website is the February 11, 2000 report of the OIG to HCFA concerning same day readmission of patients to a hospital. The OIG examined discharges and readmissions on the same day during calendar year 1996 and 1997 and found out that there were 34,500 such readmissions with associated Medicare payments of $226.6 million associated with the second admission. The OIG indicated in the report that these statistics indicated "cause for concern" on several grounds. The first is quality of care relating to a possible premature discharge of the patient. The second area of concern was billing and overpayment. The review indicated that in a number of such readmissions, there were additional services which should have been billed to the first day, medically unnecessary admissions, a lack of documentation and instances of DRG upcoding.

The OIG recommended, and HCFA agreed, that there should be closer scrutiny of readmission claims and reviews at hospitals with a higher than average rate of readmissions, including an examination of whether the same DRG was used for both admissions. As a result of the recommendations, it is likely that Peer Review Organizations (the federally funded local organizations which review appropriateness of care provided to Medicare patients) will include same day readmissions within their Scope of Work. In addition, HCFA has said that it will explore the feasibility of suspending payment for same day readmissions, pending verification of the appropriateness of the second admission or of the initial discharge.

Hospital compliance officers might want to conduct a brief preliminary survey to see if this issue is a concern in their hospitals. However, the broader lesson for all providers is that as part of your compliance efforts, you should be using available resources, such as the OIG website, to monitor new compliance issues which come to light and take appropriate action to ascertain whether they are relevant to your organization.

For further information, please contact: Peter Parvis at 410.244.7644 or by e-mail.