Policy on Hiring External Auditors and Consultants

WellSpan Health in York, Pennsylvania, developed this policy to ensure its departments follow certain steps before hiring external auditors and consultants, said Sue Shollenberger, director of corporate compliance-east. Departments create risks if they independently hire auditors or consultants without looping in compliance and don’t share results, she said.^[1] Contact Shollenberger at sshollenberger@wellspan.org.

WellSpan Health Manual of Administrative Policy

Policy # External and Consultant Review – Coding/Billing/Documentation

WellSpan Health adopts the following policy and procedure for the following specifically named entities:

Apple Hill Surgical Center
VNA Home Health and Services
WellSpan Medical Equipment
WellSpan Medical Group
WellSpan Pharmacy
WellSpan Philhaven
WellSpan Surgery and Rehabilitation Hospital
WellSpan Ephrata Community Hospital
WellSpan Gettysburg Hospital
WellSpan Good Samaritan Hospital
WellSpan York Hospital

PURPOSE – To guide WellSpan Health employees when receiving external audit requests or considering externally hired consultants/auditors to assess or address operational issues related to compliance with rules and regulations, including, but not limited to, documentation, billing, coding guidelines, and other rules or regulations governing healthcare services (OSHA, Human Resources, etc.).

POLICY AND PROCEDURE: Hiring External Consultants/Auditors

It is best to determine, prior to engaging a consultant, that one is truly required. If department management believes that help is needed with coding, billing, or documentation, please consult with the Compliance Department directors regarding the following, when considering any compliance-related audits, reviews, or consultations:
1. What is the purpose of the review?
2. What potential compliance risks have been identified, requiring this review?
3. What expertise is available in-house?
4. If it is necessary to obtain outside expertise, what consideration was given to selecting the external consultant? Are they the best match for WellSpan?
5. Should the engagement be conducted under attorney-client privilege? General Counsel or an Associate General Counsel may be contacted to review.
Ensure contract is developed in compliance with MAP policy #149 Contracting.
Ensure that results from external reviews are reviewed by appropriate management oversight, ensure that any necessary billing corrections are made to accounts and/or paybacks made to payers, and ensure any necessary corrective actions are implemented.
1. Share actual draft and final written reports with appropriate department management. Also share with Corporate Compliance director if the review is related to documentation, billing, and/or coding guidelines or regulations.
2. Review report with appropriate management to determine if there is agreement with the consultant’s results. Document results of that review. Most likely they will fall into one of three scenarios:
  1. Agree with all findings and recommendations from the consultant, and report stands as final.
  2. Disagree with some findings/recommendations, and these are discussed with the consultant who agrees with us and revises the final report accordingly
  3. Disagree with some findings/recommendations. Consultant does not agree, and you agree to disagree. Document why you disagree with supporting rational and maintain this documentation with the consultant’s report.
3. Review report with appropriate management and determine if any corrective action needs to take place for any identified deficiencies. Items that may need corrective action or updates may include, but are not limited to:
  1. Policies and procedures may need to be reviewed and updated.
  2. Workflows may need to change.
  3. Bills may need to be corrected and/or paybacks of any overpayments may need to be made to payers.
  4. Education may need to be provided to staff.
4. Develop correction action plan (CAP), ensuring all identified deficiencies are addressed, and review with appropriate management.
5. Submit CAP to Corporate Compliance for review when the review is related to documentation, billing, and/or coding guidelines or regulations.
6. Implement CAP in a timely manner.
7. Review to ensure CAP is working as intended within one month of implementation.
8. Plan periodic monitoring for an appropriate length of time to ensure continued compliance. Discuss periodic monitoring plan with Corporate Compliance prior to implementation when the review is related to documentation, billing, and/or coding guidelines or regulations.
9. Implement periodic monitoring:
  1. Document review results.
  2. Share results with appropriate management.
  3. Share results with Corporate Compliance director when the review is related to documentation, billing, and/or coding guideline or regulations.
  4. Maintain review results for 10 years.

POLICY AND PROCEDURE: External Review Requests

For any other audit requests or review results received by the department, please notify Corporate Compliance immediately. Corporate Compliance reviews all external requests for audit, external requests for records, and external audit results. External audits usually have strict time frames regarding submission of medical records and appeal time frames. Additionally, lessons learned from audit results may be shared across WellSpan, for purposes of performance improvement.

SCOPE: This policy applies to all entities governed by WellSpan Health.