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 |
Sample Internal Audit Plan
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