A. Audit Policies. Auditing is a significant part of the Clinics compliance efforts.
Properly executed, audits will enable Clinic to identify conduct which may violate the federal and state laws or detect weaknesses in the claim development and submission process. Audits also will enable Clinic to appropriately target and measure the effectiveness of its educational efforts, ensure that appropriate corrective actions have been taken and quickly identify problems in the claim development and submission process which give rise to civil or criminal exposure to the Clinic.
In furtherance of its obligations as a federally qualified health center and its role as a participant in Medicare, Medi-Cal and other government funded healthcare payment programs, Clinic has adopted these Audit Policies to assist in its efforts to monitor the accuracy of claims. The Audit Policies are adopted to ensure that representative claims submitted by the Clinic are periodically reviewed in a manner which will enable Clinic promptly to identify deficiencies in the claim development and submission process which may result in inaccurate claims.
1. Auditing Process. The Clinic will conduct audits in accordance with an audit schedule established from time-to-time by the Clinic Compliance Committee. The audits will be executed in accordance with the policies and procedures contained in the applicable auditing tools or protocol utilized by the Clinic. Clinic will devote such resources as are reasonably necessary to ensure that the audits are (1) adequately staffed; (2) by persons with appropriate knowledge and experience to conduct the audits; (3) utilizing audit tools and protocols which are periodically updated to reflect changes in applicable laws and regulations.
2. Audit Plan.
(a) New Employee Audits. It is the policy of the Clinic and the responsibility of each Clinic manager to ensure that employees who are new to a position which has a direct impact on the claim development and submission process are provided adequate and appropriate training. One mechanism for ensuring that each new employee adequately understands the essential element of his/her job functions sufficiently to ensure the accuracy of the Clinics claims is to audit the new employees work. Accordingly, it is the policy of the Clinic to review the work of new employees in the manner set forth below: i. Billers and Coders. Each employee whose principle function includes the billing or coding of claims shall have all of such employee's claim-related work reviewed by the employee's manager, or an experienced co-worker, for a period of not less than sixty (60) days following the employees commencement date in the position, or such later date as the manager is satisfied that the accuracy of employee's claims justify cessation of the reviews. ii. Patient Care Providers. Patient care providers shall be provided written guidelines with respect to documenting services rendered by such providers. During the first sixty (60) days of employment, all of the providers documentation shall be reviewed to ensure that the provider is accurately and completely documenting the services rendered by the Clinic.
For the purpose of this policy, the term provider includes physicians, nurses, allied health professionals and other persons who may document the delivery of services in the provider's records (including medical records).
(b) Periodic Audits. The Clinic will conduct periodic audits of claims submitted to the Medicare and Medi-Cal programs. At a minimum, Clinics audit activities shall consist of the audit of not less than fifty (50) claims annually of every individual provider.
(c) Complaince Audits. Upon receipt of a credible allegation or complaint alleging improper or inaccurate billing practices, the Clinic shall review the matter, including any appropriate audit, in accordance with the provisions of Clinics Compliance Plan.
3 Conducting the Audit
(a) Participants. The Clinic will involve key members of the Clinic financial department and clinic staff in the auditing process. When appropriate, the Clinic will engage outside resources to assist it in the auditing process.
(b) Sample Selection. Sample selection is an important part of the auditing process as the integrity of the sampling process directly affects the reliability of the outcome. Sample selection should be done in a manner that ensures the integrity of the samples selected. Where a sample selection is used for auditing, the audit will utilize statistically valid sampling methodologies for baseline, new employee or periodic audits.
(c) Use of Audit Tools. The audit tools which are a part of auditing process should be designed to be simple and comprehensive tools for auditing various types of claims. Each audit tool should contain both questions that need to be answered in the auditing of the claims as well as references to applicable rules which relate to or support the question.
(d) Audit Results. When the audit process is completed, it is incumbent upon the Clinic auditors to carefully review the audit results and do the following: i. If the result of the audit suggests or demonstrates that the Clinic received an overpayment that is more than insubstantial, the Clinic auditors will report their findings to the Compliance Officer in order for an evaluation of whether the Clinic needs to make restitution. ii. If the Clinic auditors uncover practices or procedures which, though not resulting in overpayments, are out of technical compliance with state or federal requirements or good accounting practices, the Clinic will promptly initiate steps to modify the claim development and submission process to ensure that the governments technical billing requirements are met.