Independent Review Organization – old

Developed to ensure that the Client is compliant in its review activities of its billing and coding practices and compliance obligations under the Corporate Integrity Agreement (CIA) and Medicare rules and regulations, HMI will perform the Claims Reviews required under the Client’s CIA, prepare required reports for the OIG, make recommendations for Client’s corrective action plan, and provide necessary staff training and education on current coding and billing methodologies.

Review/Audit & Deliverables: HMI shall randomly select claims for the Discovery Sample and/or Full Sample, as required. If the results of the Discovery Sample support the need to conduct a Full Sample review, then HMI will also perform the systems review required under the CIA. The claims supporting documentation in the patient medical record will be reviewed against applicable billing and coding regulations to determine whether the claim submitted was correctly coded (e.g., ICD-9-CM, DRG, CPT/HCPCS, HHRG, etc.), billed, and reimbursed. HMI will prepare the required review reports revealing the results of the Claims Review in accordance with the Client’s CIA. HMI will also prepare a spreadsheet report of the claim review results. HMI will make recommendations to the Client for a corrective action plan related to any deficiencies uncovered as a result of the review.

Why contract with HMI?

HMI has been providing hospitals and physicians with compliance reviews and services since 1989. Our organization was founded on the principle of giving the provider community a resource to address potential non-compliant practices, establish action plans, develop policies and procedures, and to become more knowledgeable of the coding rules and regulations. The OIG’s Annual Work Plan and auditing activities are monitored by HMI on a monthly basis. We have worked with the local U.S. Department of Justice (DOJ) from both sides, representing them in cases against providers as well as for the benefit of providers in challenging the DOJ’s findings. Our experience also involves educating DOJ auditors as well as agents working on behalf of the OIG and FBI.