|
Audit Subject |
Purpose |
Scope |
Lead Person Responsible |
Department |
Projected Timing |
|---|---|---|---|---|---|
|
Medical Necessity of Diagnostic CT and MRI |
To determine compliance with CMS 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 |
1st 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, vendors |
100% review of exclusion monitoring reports for past 12 months; validate a random sample of exclusion reviews reported |
[name] |
Compliance |
1st Quarter |
|
Evaluation & Management Documentation & Coding |
To determine compliance with E/M coding guidelines. |
Retrospective review of medical records with DOS January 1-March 31, 20xx Statistically valid random sample |
[name] |
Compliance |
2nd Quarter |
|
Physician Contract Review |
To assess compliance with Stark and/or Anti-Kickback Statute; to assess compliance with terms of contract; to review physician compensation |
Small physician practice – all contracts. Large organization – random sample |
[name] |
Compliance and Legal |
3rd Quarter |
|
HIPAA Privacy & Security Measures Implemented for Telehealth |
To determine if provider is using approved telehealth platform; to determine whether a BAA exists; to determine if informed consent for telemedicine was obtained from the patient; to determine whether a system for monitoring communications containing ePHI have been implemented; to determine whether only authorized users have access to ePHI |
Statistically valid random sample |
[name] |
Privacy and Compliance |
4th Quarter |
Chapter 4: Evaluation Processes, Investigations, and Noncompliance Response
Resource: Sample Compliance Program Audit Plan
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Navigation
Table of Contents
- Front Matter
- Chapter 1: Healthcare Compliance Programs: From Murky Beginnings to Established Expectation
- Chapter 2: Healthcare Compliance Program Fundamentals
-
Chapter 3: Running an Effective Compliance Program
- Introduction to Running an Effective Compliance Program
- Developing Core Departmental Relationships
- Conducting an Organizational Compliance Assessment
- Hiring Compliance Staff
- Job Description, Compliance Officer
- Job Description, Vice President of Corporate Compliance
- Building Trust with Senior Management and the Board
- Educating Management and Physicians on Accountability
- Educating the Board and Defining Its Role
- Resource: Sample Board Report 1, Audit Status Update
- Resource: Sample Board Report 2, Quarterly Report
- Resource: Sample Board Report 3, Compliance Work Plan
- Resource: Sample Board Report 4, Annual Compliance Risk Assessment
- Risk Assessment and Management
- Resource: Sample Heat Map
- Sample Risk Assessment Summary
- Resource: Sample Risk Committee Charter
- Resource: Sample Risk Rating Survey
- Compliance Policies, Procedures, and Codes of Conduct
- Sample Policy Template
- Resource: Sample Policy Implementation Master Tracker
- Resource: Sample Written Standards Matrix
- Communication and Education
- Resource: Sample Communication Plan
- Compliance Training
- Resource: Designing Your Annual Compliance Education
- Resource: Sample Attestation Form
- Internal Reporting Systems
- Resource: Sample Non-Retaliation Policy
- Resource: Sample Corporate Compliance HelpLine Policy
- Resource: Reporting Poster
-
Chapter 4: Evaluation Processes, Investigations, and Noncompliance Response
- Introduction to Evaluation Processes, Investigations, and Noncompliance Response
- Government and Professional Resources
- Monitoring
- Auditing
- Resource: Sample Compliance Program Audit Plan
- Program Self-Assessment
- Internal Investigations
- Resource: Sample Checklist for Assessing Investigation Capabilities
- Resource: Sample Internal Investigations Policy
- Resource: Sample Upjohn Warning
- Resource: Sample Instructions to Witnesses
- Resource: Sample Evidence Collection Worksheet
- Resource: Sample Key Allegations Worksheet
- Resource: Sample Key Facts Worksheet
- Resource: Sample Investigation Report Form 1
- Resource: Sample Investigation Report Form 2
- Resource: Sample Policy Against Retaliation
- Discipline and Incentives
- Resource: Sample Evaluation Form
- Resource: Sample Recognition Letter
- Corrective Action Plans
- Root Cause Analysis
- Self-Disclosure and Return of Overpayments
- External Investigations
- Government Settlements: Corporate Integrity Agreements and Integrity Agreements
- Resources
- Auditing
-
Board and Committee Reports and Documents
- Resource: Sample Compliance Committee Charter
- Resource: Sample Compliance Committee Meeting Agenda
- Resource: Sample Compliance Committee Meeting Minutes
- Resource: Sample Compliance Committee Work Plan
- Resource: Sample Corporate Compliance Report
- Resource: Sample Governance, Compliance, and Ethics Committee Charter
- Resource: Sample Quality Committee Charter
- CMS Conditions of Participation
- General Compliance Program
-
Human Research
- Resource: Sample Deferral Checklist
- Resource: Sample Exempt Research Guidance Summary
- Resource: Sample Flexible Guidance Summary
- Resource: Sample Project Transition Form
- Resource: Sample IRB Review Worksheet/Checklist
- Resource: Sample Limited IRB Review Guidance Summary
- Resource: Sample Minimal Risk Research Guidance Summary
- Resource: Sample Human Research Transition Chart
- Resource: Sample Single IRB Review Guidance Summary
- Institutional Research
- Internal Investigation
- Measuring Program Effectiveness
- Monitoring
- Post-Acute Care
- Provider-Based Rules and Regulations
- Risk Assessment
-
Chapter 5: Key Laws in Healthcare Compliance
- Anti-Kickback Statute
- Civil Monetary Penalties Law
- Emergency Medical Treatment and Labor Act
- False Claims Act
- Foreign Corrupt Practices Act
- Health Information Technology for Economic and Clinical Health Act
- Health Insurance Portability and Accountability Act of 1996
- Physician Payments Sunshine Act (Affordable Care Act)
- Physician Self-Referral Law (Stark Law)
- Resource: Stark Law Compliance Checklist for Commercial Reasonableness Review
- Resource: Sample Stark Law Compliance Checklist for Employee Arrangement Exception
- Resource: Sample Stark Law Compliance Checklist for Fair Market Value Arrangement Exception
- Resource: Sample Stark Law Compliance Checklist for Personal Services Arrangement Exception
-
Chapter 6: Healthcare Compliance Risk Areas
- Artificial Intelligence
- Clinical Research
- Conflicts of Interest
- Contracts with Referral Sources
- EMTALA
-
Health Information Management
- Health Information Management: Coding Compliance Audits and Third-Party Reviews
- Health Information Management: Coding with ICD-10 Clinical Modification (ICD-10-CM)
- Health Information Management: Coding with ICD-10 Current Procedural Terminology/Healthcare Common Procedure Coding System (ICD-10-CPT/HCPCS)
- Health Information Management: Coding with ICD-10 Procedure Coding System (ICD-10-PCS)
- Health Information Management: Effects of Complex Coding Guidelines and Increased Workloads
- Health Information Management: Electronic Health Record Systems
- Health Information Management: Patient Access, Information Blocking, and the 21st Century Cures Act
- Patient Care
-
Patient Privacy and Security
- Patient Privacy and Security: Business Associates
- Resource: Business Associate Agreement Checklist and Considerations
- Patient Privacy and Security: Cyberattacks
- Patient Privacy and Security: Hybrid Work Environment
- Resource: Sample Temporary Work from Home Agreement
- Patient Privacy and Security: Identity Theft
- Patient Privacy and Security: Protected Health Information
- Patient Privacy and Security: Right to Access
- Patient Privacy and Security: Social Media
- Pharmacy
- Physician Compensation
- Post-Acute Care
- Provider-Based Rules and Regulations
-
Revenue Cycle
- Revenue Cycle: 3-Day Payment Rule
- Revenue Cycle: The 60-Day Rule—Medicare and Medicaid Overpayments
- Revenue Cycle: Advance Beneficiary Notice of Noncoverage
- Revenue Cycle: CARES Act Relief Funds
- Revenue Cycle: Credit Balances
- Revenue Cycle: Denials Management
- Revenue Cycle: Government Audits
- Revenue Cycle: Hospital Discharge Appeal Notices
- Resource 1: Detailed Notice of Discharge
- Resource 2: Notice of Denial of Medical Coverage
- Revenue Cycle: Incident-to Billing
- Revenue Cycle: Implantable Medical Device Credit Reporting
- Revenue Cycle: Surprise Billing and the No Surprises Act
- Vendor Management
- Whistleblowers
- Back Matter