BP - Health Care Compliance Association

Physician office
compliance – Are
you monitoring
your auditing and
monitoring program?
Editor’s note: Melissa Morales is a consultant
working in the Healthcare Industries section of
PricewaterhouseCoopers in San Francisco. She
may be reached by e-mail at
Melissa.Morales@us.pwc.com.
Physician compliance auditing and
monitoring programs can be unique,
depending on the practice and
type of provider operations. Such programs
require specific experience and skill sets such
as expertise in audit and coding, to determine
what areas need to be monitored and how
to develop work plans that encompass the
organization’s high risk areas. Auditing and
monitoring programs conduct various types
of review throughout the year as part of an
organization’s compliance plan to help prevent,
detect, and correct noncompliance with
regulations. The program is established on
the fundamental aspects of the organization’s
processes, such as charge capture, billing
forms, claim scrubber functionality, physician
education, compliance, and billing office
operations.
With the day-to-day perspective of an organization’s
operation, it’s not uncommon for
staff to become consumed with the routine of
scheduled reviews, which may cause them to
loose sight of the direction they are heading
and any imperative trends. It’s important
to take a step back and evaluate any data
collected and analyze those results. Careful
By Melissa Morales, CPC
analysis of such data can help identify trends
and/or abnormalities that are not often apparent
on the surface of a review. Without such
analysis, you could be missing key opportunities
for change and corrective action.
So what should be incorporated in an
auditing and monitoring program to prevent
process breakdown?
First, you must ascertain the organization’s
compliance mission and objectives, such as
safeguarding health information, assigning
subject matter experts to the audit process,
and identify key high-risk areas. Organizations
should also use the current year’s Office
of the Inspector General (OIG) Work Plan 1
as a base to identify various factors, events,
emerging issues, and any priority shifts within
Congress that may be an area of concern in
the upcoming year.
Secondly, the organization should perform a
risk assessment, and determine areas of high
concern. This will allow for better determination
of what should be a high priority within
the practice, allow for planning and implementation
of the work plan.
Thirdly, set up an internal audit plan that
outlines audit coverage, scope, and objectives,
such as formal vs. informal reviews, type of
review (e.g., compliance, coding, or payment),
and areas of concern (e.g., high dollar
procedures, or teaching physician environments).
Internal audits should have a quality
review process to verify accuracy, establish
controls, identify best practices, and measure
results against national benchmark data.
Part of the audit plan should establish a
reporting and feedback mechanism to provide
information regarding the audit and its findings.
Monthly reports should be generated
for management and those being audited
to review audit results, provide education,
establish corrective action plans, and review
any trends identified. It is imperative that the
information found through audit is communicated
to those who were audited, not just
the chiefs or management of the department.
In order to assist with accuracy rate improvement
and address any noncompliance with
regulations, everyone participating in the
audit should be notified of their results. If
there were deficiencies identified through
the audit, the reporting mechanism can help
determine what departments or areas need
to be re-evaluated and need continuous
monitoring. When auditing accuracy and
proper documentation of evaluation and
management (E&M) codes, the accuracy rate
needs to be established by the organization.
Any physician who falls below that range
should be continuously monitored until their
accuracy rate has improved.
Routine reports are instrumental in performance
improvement initiatives as well
as in making recommendations for process
improvements or corrective actions.
Fourthly, evaluate the performance of the
process by analyzing the results along various
factors as well as monitoring the process
frequently to make sure there are no loop
holes within the process.
Lastly, examining and re-evaluating your
March 2009
28
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