13 Audits and Inspections

continued on next slide Learning Objectives After this lecture, you should be able to complete the following Learning Objectives: 13.1 - Define commonly used terms, abbreviations, and acronyms. 13.2 - Identify the administrator's role in the internal and external auditing processes. continued on next slide

continued on next slide Learning Objectives After this lecture, you should be able to complete the following Learning Objectives: 13.3 – Interpret the parameters of the various types of audits. 13.4 – Evaluate the impact of governmental audits on any size facility. continued on next slide

Learning Objectives After this lecture, you should be able to complete the following Learning Objectives: 13.5 – Comprehend the appeals processes to be implemented, as necessary.

13.1 - Define commonly used terms, abbreviations, and acronyms. Key Terms 13.1 - Define commonly used terms, abbreviations, and acronyms.

continued on next slide Key Terms audit comprehensive audit concurrent covert problem current external audit continued on next slide

continued on next slide Key Terms extrapolation internal audit occult problem overt problem redetermination retrospective audit continued on next slide

Key Terms sampling audit subpoena ad testificandum subpoena duces tecum trend analysis upcoding

Introduction

Audits and Assessments An audit is an assessment of specified data points to determine compliance with previously identified standards and can be performed in virtually every department within your facility: from food service to medical services from medication inventories to patient discharges

The Administrator's Role in Auditing 13.2 - Identify the administrator's role in the internal and external auditing processes.

Uncover and Address Problems Overt problems Identify problem areas when you look for them Covert problems Concealed issues requiring deeper investigation such as trend analysis Occult problems Hidden behaviors difficult to discover

13.3 – Interpret the parameters of the various types of audits.

Types of Audits Audit = investigation focused on analyzing and evaluating certain amounts of data Retrospective audit Data pulled from past period of time Concurrent audit Data pulled from services provided now

Scope of Audits Quantity of data to be analyzed Sampling audit Comprehensive audit Time frame from which data will be drawn

continued on next slide Internal Audits Identify the specific elements to audit Decide the scope of the audit Select the audit team Provide a quiet, secure space continued on next slide

Internal Audits Specify the length of time during which the audit will occur Designate the format of the audit report and to whom the report should be given

Governmental Audits 13.4 – Evaluate the impact of governmental audits on any size facility.

External Audits Recovery Audit Contractors (RAC) Comprehensive Error Rate Testing (CERT) Occupational Safety and Health Administration (OSHA)

External Audits Department of Justice (DoJ) Office of the Inspector General (OIG) Health Care Fraud Prevention and Enforcement Action Team (HEAT) Medicare Administrative Contractors (MAC) The Joint Commission (TJC)

When Notified Verify from whom the request has come Confirm the names of the staff to act as audit liaison Review organizational policies Identify the type of record request Prepare information and documentation

The Appeals Processes 13.5 - Comprehend the appeals processes to be implemented, as necessary.

Appeals Process Confirm the auditing entity's appeals process steps. Gather the supporting documentation needed to prove your position. Confirm appeals deadlines. Set a schedule to meet all requirements.

Medicare's Five Levels of Appeals Redetermination Reconsideration Administrative Law Judge (ALJ) hearing Appeals Council review Judicial Review in U.S. District Court

Legal Investigations Subpoena duces tecum Subpoena ad testificandum Documents to be provided to court Subpoena ad testificandum Person to testify in court

continued on next slide Summary Use internal audits to uncover potential ethical and legal liabilities so they can be corrected. Federal and state government agencies have the authority to audit various areas of your facility and its personnel. continued on next slide

Summary The bottom line is that no facility, of any size, should worry about an audit because day-to-day activities should be performed every day as though an audit was impending—because it probably is.