Healthcare Compliance Forms and Tools

Medical Necessity of Diagnostic CT and MRI

To determine compliance with the Centers for Medicare & Medicaid Services guidelines, including physician order, place of service, prior authorization, documentation requirements, specificity of exam, etc.

Small physician practice may be 100% prospective review, with large organizations at 10% prospective review

[name]

Compliance

1^st quarter

Exclusion Review of Employees, Contractors, Vendors

To validate that exclusion review is being performed at hire and every 30 days on physicians, employees, contractors, and vendors

100% review of exclusion monitoring reports for past 12 months; validate a random sample of exclusion reviews reported

[name]

Compliance

1^st quarter

Evaluation & Management (E/M) Documentation & Coding

To determine compliance with E/M coding guidelines.

Retrospective review of medical records with date of service January 1–March 31, 20xx

Statistically valid random sample

[name]

Compliance

2^nd quarter

Physician Contract Review

To assess compliance with Stark and/or Anti-Kickback Statute, assess compliance with terms of contract, and review physician compensation

Small physician practice—all contracts. Large organization—random sample

[name]

Compliance and legal

3^rd quarter

HIPAA Privacy & Security Measures Implemented for Telehealth

To determine whether provider is using approved telehealth platform, whether a business associate agreement exists, whether informed consent for telemedicine was obtained from the patient, whether a system for monitoring communications containing electronic protected health information (ePHI) has been implemented, and whether only authorized users have access to ePHI

Statistically valid random sample

[name]

Privacy and Compliance

4^th Quarter