Complete Healthcare Compliance Manual

Auditor and Audit Director brainstorm a list of risks for department or system being audited. For each risk identified, rate the likelihood that it could happen and the impact if it did happen.

0=UNLIKELY

1=POSSIBLE

2=PROBABLE

3=HIGHLY LIKELY

0=N/A

1=LOW

2=MEDIUM

3=HIGH

Probability of occurrence

Do managers of this process agree with risk score? (Y/N)

If management does not agree with the risk score, then rate the likelihood that the risk could happen and the impact if it did happen, considering the mitigating factors.

Initial risk score will apply if management agrees. Adjusted score may otherwise apply.

6

Poor communication between facilities and assigned CDM coordinator resulting in inefficient and untimely changes/updates & misunderstandings.

3

3

17

Services are being performed without a corresponding CDM code

3

3

3

Stakeholders (process owners/ contacts) are not clearly identified at the facility level

3

3

19

Changes to CDM are not made timely by Rev Group

2

3

14

Affected systems are not kept up-to-date as changes occur to CDM (interfacing systems, order entry systems) - integrity and consistency not confirmed - Resulting in charging errors and less than optimal reimbursement

2

3

13

Charge tickets (encounter forms) are not kept up-to-date as the CDM changes occur.(Manual forms that may be used in absence of or before EHR entry)

2

3

10

Claim rejections related to codes are not reviewed / trended & forwarded to appropriate party to devise mitigating controls

2

3

7

No documented procedures at the facility level to guide chargemaster functions not performed at the corporate level. This could result in ineffective operations, untimely or inaccurate submittals, and lack of continuity of tasks

2

3

24

System / technology errors

1

3

23

Contract pricing is not maintained at facility level once approved

1

3

22

Regional chargemaster procedures not being followed / not understood

1

3

21

Unauthorized changes to the CDM are being made by personnel at the facility level or corporately managed facilities

1

3

20

No process for confirmation and testing of changes made at facility

1

3

15

CDM change form/process is not readily understand by all stakeholders

1

3

11

Charge descriptions used for CDM do not adequately describe service provided - resulting in difficultly relating to similar CPT/HCPCS code & requesting duplicate CDM with diff description

1

3

8

CDM codes entered incorrectly (manual errors on charge form or in chargemaster)

1

3

5

There is not one CDM Coordinator/ contact at each regional facility responsible for filtering/maintaining all CDM information

1

3

4

Stakeholders and process owners are not clearly identified at the Corporate level to facility level chargemaster process owners

1

3

2

Undercharging for services

1

3

1

Overcharging for services

1

3

26

No process in place to audit facility CDM to ensure it reflects Corporate CDM (if managed) or is in-line with facility expectations

2

2

12

Charge ticket formats are not standardized at facility leading to some confusion regarding the correct services to charge

1

2

9

Billable service items are missing from CDM (new or updated codes, secondary codes, large dollar supplies or devices that can be billed separately)

1

2

25

CDM codes entered incorrectly (manual errors on charge form or in chargemaster)

1

1

18

Applicable staff (clinical dep, directors etc.) not educated on chargemaster and its effect on Corporate Compliance

1

1

16

Each facility does not have chargemaster group/ committee responsible for oversight of facility level chargemaster processes such as requests for changes, review of CDM codes

1

1

Exhibit B

Template for Final Risk Assessment