Every facility should provide monitoring and auditing of its activities by conducting routine reviews, medical chart auditing, coding audits, risk-based reviews, and audits of physician relationships and payments made to potential referral sources. Based on the type of review, audits and reviews may be conducted monthly, quarterly, annually, or may be conducted in response to regulatory changes or identified risk areas.
I. Medical Chart Auditing: The Medical Auditor (Nurse Auditor) should perform monthly concurrent account audits to identify charges issues not normally found during the course of defense audits. A concurrent audit is defined as a complete audit on a non-disputed account, completed within 30-days of patient discharge. Concurrent audits should include all Payor Types. Financial Classes and Patient Types. The audits samples for concurrent review must include no less than 10 patient accounts. The sample must be random for both the inpatient and outpatient and should equal one-third of single day’s hospital revenue. The scope of a billing audit is limited to verifying the charges on the detailed hospital bill are accurate and that charges represent services rendered to the patient and are ordered by physician. The Medical Auditor should assist the appropriate Department Managers, Nursing, Ancillary Departments with maintaining and/or developing Charging Protocols and Policies in all revenue producing departments.
II. Coding Audits: Coding managers should perform quarterly or semi-annual coding accuracy reviews at each facility. Reviews include correct assignment of ICD-10 and CPT-4 codes as well as DRG assignment. Billing errors identified during the course of the review are included on the corrective action plan, and overpayments are refunded. The results of all reviews are reported to facility senior management, and a corrective action plan is implemented, if necessary.
III. Risk Based Reviews and Other Specialized Reviews: In each facility, Compliance Department should conduct a variety of risk-based audits and reviews. The audit results and findings should be forwarded to facility senior management and work with the facilities to develop, implement, and monitor corrective action plans. In addition, education, policy changes and disciplinary action are implemented as appropriate.
Based on the summarized audit findings presented by various departments a Corrective Action must be implemented in order to identify and resolve any issues. Elements of each corrective action plan include: (1) identification of the issue; (2) revisions to policies and procedures, if necessary; (3) training on those policies and procedures, or retraining on established policies and procedures; (4) monitoring to ensure compliance; and (5) appropriate disciplinary action in the event of non-compliance.
Julie Doumad RN, BSN, CCFA, CMAS
Director of Audit Services