The OIG Trauma Audit Report Findings and CMS’ Response (Live)-Handout: OIG Report

Handout: OIG Report

Pdf Summary

The November 12, 2025 presentation by Valerie A. Rinkle, M.P.A., C.H.R.I., President of Valorize Consulting LLC and hosted by the Trauma Center Association of America (TCAA), provides a comprehensive overview of the Office of Inspector General’s (OIG) recent audit on hospital trauma team activation billing and Centers for Medicare & Medicaid Services’ (CMS) response.<br /><br />The OIG audit examined Medicare hospital claims charging for trauma team activations, focusing on whether charges met federal criteria for medical necessity, appropriate pre-notification, team activation timing (prior to patient arrival), correct coding, and proper trauma center verification or designation. Key findings highlighted frequent issues such as lack of documented pre-arrival notification and trauma team activations after patient arrival, which, according to OIG guidelines, do not justify billing trauma activation fees.<br /><br />OIG made four main recommendations to CMS, including addressing an estimated $2.4 billion in unallowable trauma activation charges affecting payment rates, enhancing oversight and compliance post-audit period, revising CMS guidance with clearer trauma activation criteria (incorporating American College of Surgeons (ACS) standards), and providing hospitals with more frequent education on billing requirements.<br /><br />CMS partially disagreed with OIG’s findings and criteria, specifically the methodology used, but agreed to review guidance and improve education. CMS emphasized that trauma team activation coding is complex, involving codes for activated and fully performed responses versus activations called off upon patient arrival, necessitating individualized medical review.<br /><br />The presentation stressed hospitals must ensure trauma activation charges align with established designating criteria, documentation adequately supports medical necessity and pre-notification, and billing complies with HIPAA mandates and National Uniform Billing Committee (NUBC) coding standards (including correct revenue code 068X usage linked to trauma center level).<br /><br />Best practices include conducting multidisciplinary self-audits, reviewing trauma policies, verifying correct coding and documentation, and closely collaborating among trauma, compliance, revenue cycle, and coding professionals to mitigate audit risks.<br /><br />The TCAA continues to advocate with CMS and educate trauma centers on compliance to optimize billing accuracy and defend against improper payment denials or recoupments, ensuring trauma activation services are appropriately charged and reimbursed within regulatory frameworks.

Keywords

OIG audit

trauma team activation billing

Medicare hospital claims

medical necessity

pre-notification

CMS response

trauma center verification

billing compliance

coding standards

audit recommendations