Catherine Boerner (cboerner@boernerconsultingllc.com) is President of Boerner Consulting LLC in New Berlin, WI.
Many organizations struggle with performing an annual compliance risk assessment. One idea is to think about and incorporate your recovery audit contractor (RAC) and other government audits as an ongoing compliance risk assessment process. Keep track of the areas that are causing denials and the error rates, not just for Medicare and Medicaid fee-for-service, but maybe also Medicare Advantage.
Compliance can partner with revenue integrity and patient financial services and ask these questions:
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What is the error rate on a government/RAC audit?
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Why were there unfavorable findings?
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Who needs to know about it so we don’t get these errors in the future?
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What training is needed?
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How do we document that training?
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What is the root cause?
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Are we concerned this is a systemic problem (i.e., we have been doing this wrong for a while)?
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Is there a particular local coverage determination or regulatory change or system change or other event that happened that caused these claims to be billed in error?
Compliance can also get ahead of some of these types of audits by looking at the list on the RAC website. This is a great resource to get the information on what is being audited and why. For example, new approved RAC topics can be found on the Centers for Medicare & Medicaid Services website.[1]
The other area you could consider adding to your risk assessment process is a list of risk areas of recent self-disclosures by other organizations. You can access these on the Office of Inspector General website.[2]
These three areas can be used to shape your ongoing compliance risk assessment process and result in adding ongoing compliance audits to your audit plan.