1. 13
Audits and Inspections

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Learning Objectives
After this lecture, you should be able to complete the following Learning Objectives:
Define commonly used terms, abbreviations, and acronyms.
Identify the administrator's role in the internal and external auditing processes.
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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.
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4. 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.

5. 13.1 - Define commonly used terms, abbreviations, and acronyms.
Key Terms
Define commonly used terms, abbreviations, and acronyms.

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Key Terms
audit
comprehensive audit
concurrent
covert problem
current
external audit
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Key Terms
extrapolation
internal audit
occult problem
overt problem
redetermination
retrospective audit
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8. Key Terms sampling audit subpoena ad testificandum
subpoena duces tecum
trend analysis
upcoding

9. Introduction

10. 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

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

12. 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. 13.3 – Interpret the parameters of the various types of audits.

14. 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

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

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Internal Audits
Identify the specific elements to audit
Decide the scope of the audit
Select the audit team
Provide a quiet, secure space
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17. 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

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

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

20. 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)

21. 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

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

23. 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.

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

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

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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.
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27. 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.