Auditing

Sample Internal Audit Plan

Fiscal Year Internal Audit Plan

Risk Area for Audit Activity

Risk

Frequency

Sample Size

Locations

Assigned To

Date Completed

Hospitals

Two-Midnight Rule

Failure to document and bill short-stay hospital admissions consistent with the Centers for Medicare & Medicaid Services requirements

Annual

25 claims with a length of stay of 0 or 1 day per location

All acute care hospitals

Major Joint Replacement

Failure to document and bill services that support medical necessity per requirements

Annual

25 major joint claims per location

All acute care hospitals

Provider-Based Status

Failure to meet the licensure, clinical integration, financial integration, and other requirements necessary to bill as a provider-based entity

Annual

N/A

All provider-based entities

Clinical Trial Billing

Failure to properly document and bill for services that should be covered by the study sponsor

Annual

25% of open clinical trials

All acute care hospitals

Discharge Disposition

Failure to meet requirements of the post-acute care transfer policy

Annual

25 claims per location

All acute care hospitals

Wounds and Falls

Failure to accurately document and report wounds and falls

Annual

5 wound and 5 fall residents

Top 10 wound facilities & top 10 fall facilities

Credit Balance

Failure to appropriately bill, resulting in potential False Claims and 60-Day Repayment Rule

Annual

10% of total dollars

N/A

Accuracy of Survey Data

Failure to accurately report civil monetary penalties and F-Tags

Annual

All annual surveys for selected facilities

All facilities that have had a 2018 annual survey

Wrongful Discharges

Failure to discharge appropriately could lead to quality-of-care issues, increased legal fees, and claims/lawsuits

Annual

25 discharges per location

All acute care hospitals

Skilled Nursing Facilities

Skilled/Medical Necessity Clinical Audits

Failure to document and bill claims appropriately supporting medical necessity; potential false claims

Quarterly

5 residents RU> 30 days

5 facilities

Resident Trust Fund Monitoring & Follow-Up

Misappropriation of funds

Monthly

100%

All

Purchase Card Monitoring & Follow-Up

Misappropriation of funds

Monthly

100%

All

Net Revenue Testing

Failure to document and bill claims appropriately; potential false claims

Quarterly

10% of census for prior 2 months billed

2–3 facilities

Resident Trust Fund Testing

Misappropriation of funds

Quarterly

2 months

2–3 facilities

Purchase Card Testing

Misappropriation of funds

Quarterly

2 months

2–3 facilities

Preadmission Screening & Resident Review (PASRR)

Failure to meet federal requirements

Quarterly

10% of census for prior 2 months billed

2–3 facilities

Census Balancing

Failure to document and bill claims appropriately

Quarterly

2 months

2–3 facilities

Quality Assurance/Performance Improvement (QAPI) Meeting Minutes

Failure to meet survey requirements and process improvement

Quarterly

2 months

2–3 facilities

Home Health

Medical Necessity Audits

False claims

Annual

10%

All

Physician Enterprise

Coding Audit

Failure to document and bill claims appropriately; potential false claims

One time

Will review with External auditor

All

Rehabilitation Company

Skilled/Medical Necessity Audits

Failure to document and bill claims appropriately; potential false claims

Quarterly

5 residents RU> 30 days

5 facilities

Information Technology

IT Penetration Audit

Security, data breach, HIPAA

One time

Will review with external auditor

All

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