BOS GEN 001 Audit by xQ826l5g


									DEPARTMENT:. Operations Support / Billing            POLICY DESCRIPTION: BILLING - Audit &
  Compliance                                           Monitoring
PAGE: 1 of 2                                         REVISED:
APPROVED: 01-16-1998                                 RETIRED:
EFFECTIVE DATE: 01-16-1998                           REFERENCE NUMBER: BOS.GEN.001

SCOPE:       Business Office           Nursing
             Admitting                  Ancillary Services
             Finance                    Health Information Management
             Administration             Utilization Review
             Revenue Integrity
PURPOSE: To ensure an effective audit and monitoring process has been established for each
billing policy and procedure.

POLICY: In order to ensure compliance with billing policies and procedures a facility billing audit
committee will be established. The committee’s structure, objectives, and required documentation are
as follows:

The Facility Ethics and Compliance Officer (ECO) must establish a Facility Billing Compliance Audit
Committee with the following members:

       a)   Chief Financial Officer
       b)   Business Office Director
       c)   Ancillary Department Director (e.g. Laboratory Director)
       d)   Health Information Management Director
       e)   Physician Advisor
       f)   Other individuals as deemed appropriate (e.g. Admitting Supervisor, Billing Supervisor,
            Revenue Integrity, Utilization Review).

The Facility Billing Compliance Committee will meet on a monthly basis and perform the following:

       a) Audit each policy and procedure in accordance with the Audit Tool and Instructions or as
          specified in each policy.
       b) For those policies in which a random sample selection is required, utilize the Random
          Sampling Instructions document (Attachment B).
       c) Prepare an Action Worksheet each month (see Attachment A). For each policy in which an
          error was present, the root cause of the error (e.g. masterfile/dictionary issues and/or process
          issues) must be identified and addressed. If the error appears to be isolated to one given
          account, then that account should be rebilled appropriately. If the error suggests the
          possibility of other similar errors, a further analysis should be conducted with regards to
          bills issued on or after the implementation date of the policy. Any erroneous bills should be
          rebilled from the date the specific billing policy was implemented. Accounts with errors
DEPARTMENT:. Operations Support / Billing            POLICY DESCRIPTION: BILLING - Audit &
  Compliance                                           Monitoring
PAGE: 2 of 2                                         REVISED:
APPROVED: 01-16-1998                                 RETIRED:
EFFECTIVE DATE: 01-16-1998                           REFERENCE NUMBER: BOS.GEN.001

          prior to the date of the specific billing policy implementation should not be rebilled as they
          will be addressed as part of the national investigation. Any errors noted which relate to
          accounts prior to policy implementation should not be investigated by the facility but
          instead must be reported to your facility Operations Counsel for review.
       d) As error rates are reduced to 0% for each policy which is audited on a monthly basis, the
          sample size of the audit function may be reduced in accordance with the Random Sampling

   The Audit Committee must clearly document at a minimum the following elements: date,
   attendees, testing performed with the Audit Tools, Error Rates, Action Taken, Status of Action in
   place, etc.

   It is the responsibility of the Ethics and Compliance Officer (ECO) to ensure adherence to the

OIG Model Compliance Plan for Clinical Labs (March, 1997), Federal Register Vol. 62, No. 41
                                              ATTACHMENT A
                                     BILLING AUDIT ACTION WORKSHEET


Policy & Procedure   Error     Issue / Action to be Taken   Responsible   Timeframe    Status / Comments
    Description      Rate(s)                                   Party
                                              ATTACHMENT A
                                     BILLING AUDIT ACTION WORKSHEET
Policy & Procedure   Error     Issue / Action to be Taken   Responsible   Timeframe   Status / Comments
    Description      Rate(s)                                   Party
                               ATTACHMENT B
                           Billing Policy Compliance
                         Random Sampling Instructions

To ensure appropriate sampling techniques are performed to monitor each billing policy,
the following procedures must be utilized to select each sample. The sample sizes and
selection process outlined in these instructions will not yield statistically valid samples
for a given month, at a given facility. However, over time, this process will provide valid
statistical data to analyze the population. Samples should be selected and documented as

1. Maintain daily system reports of registration activity preferably to include the patient
   name, patient number, patient type, financial class, and type of service for ease of
   sample selection (e.g., Registration Activity Report (Bill:Bill09) if using the Patient
   Accounting System) in a central location, in date order, and by month. Retention and
   central control over these reports will help ensure proper random sampling techniques
   can be performed and documented as outlined below.

2. By the end of each subsequent month (starting 30-45 days after the policy is
   implemented), select a sample of 15 accounts for each policy from the “Registration
   Activity Report”. NOTE: the accounts may be used for all applicable policies, to
   the extent possible. If no errors are noted for a given policy, the sample size may be
   reduced to 5 in the subsequent months. If any errors are noted, the subsequent
   month’s sample should be 15. The samples must be selected as follows:

  a) Count the number of pages for the registration activity reports accumulated for the
     month under review.

  b) To determine what page to begin the sample selection on, divide the total number
     of pages by the sample size. For example, if the reports for the month of February
     consisted of 90 pages and the sample size is 15, divide 90 by 15 to arrive at a value
     of 6. (If sample sizes of 15 and 5 will both be used (for different policies), 15
     should be considered the “sample size” for all policies even though only 5 may be
     selected for testing.) When dividing the sample size by the total number of pages,
     if the result is not a “whole” number, then round up to the next number for .5 and
     greater and round down for less than .5.

  c) Select an account from each identified page in b) above (e.g., select an account
     from every 6th page of the “Registration Activity Report” per the above example)
     as follows:

         Assume each month under review has been assigned the corresponding number
          for that month: January = 1, February = 2 … December = 12. Select an
          account on each identified page in b) above which corresponds with the
          number assigned to the month under review. For example, if the month under

         review is February, select and highlight the second account on each identified

        For each account selected, determine if the account meets the following criteria
         by reviewing the charge detail on the on-line patient accounting system:

            The payor present on the account is a federally funded payor for which this
             billing policy applies.

            The account includes Laboratory services/procedures for the procedures
             under review.

            Patient type is “Outpatient” (including Emergency Room, Same Day
             Surgery, Observation, etc.).

        If the account selected does not meet the above criteria, select the next account
         on the page and determine if the criteria are met. Continue this process until an
         account is located which meets the above criteria and an account has been
         selected for each procedure under review. If you reach the bottom of the page,
         and the account sample is not complete, continue the same process on the next
         page. (Note: The same account may be used for multiple policies to the
         extent possible).


                Assume the month is February and the total pages are 90. The sample
                 selection would start on page 6 (90 pages divided by a sample size of
                If the second account on the report (February = 2) does not meet the
                 defined criteria above, for example, the payor class was commercial,
                 proceed to the next account.
                Assume the next account meets the defined criteria and includes a
                 venipuncture and a CBC procedure. Document the account on both
                 the Outpatient Specimen Collection and Hematology worksheets.
                Proceed to the next account and continue this process until one
                 account has been identified for each procedure being audited.
                Proceed to the 12th page of the report and select the second account in
                 the sample for each policy following the same process.
                Continue this process until a sample of 15 is selected for each policy.

        Log each account on the applicable “Audit Worksheet” ensuring the
         appropriate sample size is logged for each policy.

3. Clearly document the sample selection process each month and maintain this
   documentation as an audit trail.


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