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Innovating your auditing and monitoring program

Amy Bailey (abailey@hbeadvisors.com) is Principal, HBE Advisors LLC, Meridian, ID. Sharon Parsley (sharon-qag@outlook.com) is President & Managing Director, Quest Advisory Group LLC, The Villages, FL.

As we all know, monitoring and auditing is one essential element of every effective compliance program. However, we have seen over the years that monitoring and auditing does not receive nearly the amount of dedication of resources and attention that it may deserve.

Yes, we may spend months planning and executing on our periodic risk assessment process and do an outstanding job of gathering input from both operational areas and risk assurance functions about emerging areas of risk, the likelihood of each risk occurring, and the derivative business impacts if/when they do. But do we carefully assess and monitor the effectiveness of the activities we then create to mitigate and measure those risks considered both high likelihood and impact and which we also view as being measurable through an auditing or monitoring activity? Unfortunately, we have seen that in many programs, the activities created may not always examine each risk in a holistic or comprehensive manner.

As for revenue cycle–related risks specifically, auditors have traditionally employed largely standardized methods to evaluate compliance with applicable documentation, coding, coverage, and reimbursement rules. Some of the common tactical approaches may include items like reviewing and evaluating the following:

  1. Documentation for 5–10 encounters for each provider annually,

  2. Evaluation and management service bell curve reports,

  3. Program for Evaluating Payment Patterns Electronic Reports,

  4. Comparative billing reports, and

  5. Program integrity contractor additional documentation requests and associated findings.

While there is nothing inherently “wrong” with any of those methods, there are many questions that activities of that nature leave unanswered, such as:

  1. Was the patient seen by a qualified provider?

  2. Did the provider who signed the documentation take part in the encounter?

  3. Is the information in the medical record a correct reflection of the encounter?

  4. When was the documentation created and by whom?

  5. Is the encounter documentation unique and specific to this patient visit?

The purpose of this article is to present some battle-tested ideas for you to consider and which may shed light on whether each of your scheduled and ad hoc audits are well-designed to measure and mitigate all the compliance risks that may be present. We will try to achieve this through the discussion of some scenarios that may sound familiar to you.

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