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Healthcare Auditing Weekly

This weekly email newsletter offers health care internal auditors and compliance professionals the latest information on setting up and maintaining an effective auditing program.

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Healthcare Auditing Weekly

Issue 17, May 17, 2004

• Have there been any changes to HIPAA?

  It’s been one year since the privacy rule kicked in. Are there any changes to the rule? Do I...

Issue 51, December 28, 2004

• Auditing clinical trials

  Ensure that clinical trials research is conducted properly by developing clinical trials knowledge...

• Investigator-initiated research: Opportunities, obstacles

  Clinical trials have received a great deal of attention from the national media in recent months...

• GOV’T AUDIT INSIDER: Nevada makes unallowable Medicaid claims for vaccine progr

  Nevada made $7,917 in potentially unallowable Medicaid payments to fee-for-service (FFS) providers...

Issue 50, December 21, 2004

• Organizational independence

  This week we’ll focus on the significance of organizational independence.

• Keep HIPAA retraining fresh

  You’re leading the annual HIPAA retraining session, and you feel like you’re talking to...

• GOV’T AUDIT INSIDER: Very good compliance in New York

  Senior Blue Health Plan, a division of the health benefits firm HealthNow New York, Inc., complied...

Issue 49, December 14, 2004

• External impairments to independence

  Last week we covered personal impairments to independence. This week we’ll focus on external...

• Ten steps to assess risk and evaluate controls

  Get more out of your audits by using a risk-based approach instead of traditional audit methods.

• GOV’T AUDIT INSIDER: Unallowable contingency fee payments in Virginia

  Between October 2001 and April 2003, Virginia claimed $677,964 in unallowable contingency fee...

Issue 48, December 7, 2004

• Personal impairments to independence

  This week we’ll dive deeper and examine personal impairments, which apply to anyone...

• Procedure: forming a medical necessity compliance committee

  A medical necessity compliance committee can help your organization achieve a more streamlined...

• GOV’T AUDIT INSIDER: Need for stronger controls in Arizona

  Arizona made unallowable Medicaid payments totaling $21,058 to fee-for-service (FFS) providers for...

Issue 47, November 30, 2004

• Organizational and individual independence

  According to the Office of Inspector General’s (OIG) auditing standards, audit organizations...

• Increase reimbursement through necessity audits

  Each year, healthcare facilities face increasing pressure to remain financially viable as the cost...

• GOV’T AUDIT INSIDER: Failure to report Medicaid provider overpayments in Alaska

  Alaska’s Department of Health and Social Services did not report more than $1.8 million in...

Issue 46, November 23, 2004

• Types of tests

  There are three major categories of tests within healthcare auditing.

• A step-by-step guide to Stark compliance

  The Stark law’s fine print can be a tough nut to crack, and Phase II’s exceptions are...

• GOV’T AUDIT INSIDER: A need for strengthened policies and procedures in Wyoming

  The Wyoming Department of Health incorrectly reported Medicaid provider overpayments for fiscal...

Issue 45, November 16, 2004

• Indexing working papers

  The Office of Inspector General (OIG) uses an alphanumeric system of working-paper indexing.

• CMS program integrity changes provide map for coming year

  CMS’ intentions, changes, and challenges to its program integrity initiatives for the coming...

• GOV’T AUDIT INSIDER: Late and unidentified overpayment reporting in Delaware

  Delaware’s Department of Health and Social Services did not report identified overpayments...

Issue 44, November 9, 2004

• Tests of evidence

  According the Office of Inspector General’s (OIG) auditing standards, evidence gathered by...

• Identity theft action plan

  In August, when a Washington state cancer center worker was convicted in federal court for...

• GOV’T AUDIT INSIDER: Missing documentation in Colorado

  The OIG was unable to determine whether Colorado’s 2003 Medicaid enhanced payment was correct...

Issue 43, November 2, 2004

• Tools to aid access compliance assurance

  There are a variety of tools to audit and monitor compliance with individuals’ right to...

• Make annual notices work for your laboratory

  Picture this: A hospital’s compliance officer meets with a physician to discuss lab ordering...

• GOV’T AUDIT INSIDER: Unallowable pension cost claims in Tennessee

  Blue Cross Blue Shield of Tennessee claimed $684,551 of unallowable pension costs for fiscal years...

Issue 42, October 26, 2004

• Designation of officials

  Information privacy officials (IPO) and information security officials (ISO) must keep abreast of...

• Billing Medicare for research-related injuries

  Most clinical trial documents, such as informed consent or clinical trial agreements, include a...

• GOV’T AUDIT INSIDER: Inadequate internal controls at Iowa rehab facilities

  An estimated $3.3 million in Medicaid claims from the Iowa Rehabilitative Treatment Services Group...

Issue 41, October 19, 2004

• Authorizing requirements for uses and disclosures

  When authorizing requirements for HIPAA uses and disclosures, guarantee compliance

• Taking the fear factor out of your compliance program

  Compliance is a heavy topic, so infusing compliance teams with a new dynamic and a fresh...

• GOV’T AUDIT INSIDER: Improper Medicare payments blamed on automation problems

  Medicare improperly paid approximately $187,458 from January 1, 1997, to December 31,2001 to...

Issue 40, October 12, 2004

• Work force security and information access management

  Add this to your to-do-list: Enhance your security policies and procedures by making sure everyone...

• In light of the first HIPAA privacy conviction, education takes center stage

  This summer, HIPAA played a starring role in a federal criminal conviction for the first time...

• GOV’T AUDIT INSIDER: Incomplete background and drug testing at DE nursing facili

  The Emily P. Bissell Hospital in Wilmington, DE did not comply with state drug testing and...

Issue 39, October 5, 2004

• Compiling HIPAA compliance reports

  HIPAA describes compliance reviews and outlines the responsibilities of covered entities for...

• Consultations: Help your practice meet Medicare’s billing criteria

  Your physician practice may be losing significant revenue if it is not appropriately billing for...

• GOV’T AUDIT INSIDER: A need to reinforce Medicaid compliance in New York

  The Office of Inspector General (OIG) found that an estimated $17.2 million in Federal Medicaid...

Issue 38, September 28, 2004

• Review same-day readmission documents

  Ensure appropriate Medicare billing and quality patient care by identifying red flags in same-day...

• HIPAA: Verify employees’ privacy compliance

  Audit your facility’s compliance with the HIPAA privacy rule to verify that employees are...

• GOV’T AUDIT INSIDER: ’Very good’ fiscal controls at the Georgia Department of Co

  The Georgia Department of Community Health only claimed $12,232 in costs that were not related to...

Issue 37, September 21, 2004

• Tour facilities when auditing physician practices

  When determining whether the goals and objectives of a physician practice and hospital are being...

• Audit medical necessity to increase reimbursement

  Each year, healthcare facilities face increasing pressure to remain financially viable as the cost...

• Utah state health department fails to report Medicaid overpayments

  The Utah State Department of Health did not report a total of $132,749 for Medicaid provider...

Issue 36, September 14, 2004

• Assessing risk standard in computer processing

  An understanding of the nature of an organization’s internal controls should include...

• Review procedure coding for correct reimbursement and compliance

  Ensure that your practice properly bills for in-office procedures in order to receive accurate...

• GOV’T AUDIT INSIDER: Inadequate controls for drug rebate program in Massachusett

  The Massachusetts Division of Medical Assistance’s computer system was to blame for the...

Issue 35, September 7, 2004

• Workstation use and security

  HIPAA defines "workstation" as an electronic computing device.

• Look beyond encryption to secure e-mail

  Both the privacy and security regulations require facilities to protect patients’ electronic...

• GOV’T AUDIT INSIDER

  New Jersey improperly claimed Medicare reimbursement

Issue 34, August 31, 2004

• Identify and assess evaluation and management

  To identify problem areas in evaluation and management (E/M) services, perform a baseline audit and...

• Assess your audit program using new compliance guidelines

  Make sure your organization’s compliance program is up to date as part of your ongoing...

• Incorrect billing at Massachusetts rehab facility

  After an audit, the Office of Inspector General (OIG) found that Weldon Rehabilitation Hospital...

Issue 33, August 24, 2004

• Identifying excluded individuals and entities

  Understand the following Office of Inspector General (OIG) and General Services Administration...

• Improve the revenue cycle process while increasing your facility’s financial hea

  Despite their focus on healing, hospitals are businesses. Add value to your organization by helping...

• GOV’T AUDIT INSIDER: Uninsured children in Virginia

  Virginia has an opportunity to enroll uninsured children in the State Children's Health Insurance...

Issue 32, August 17, 2004

• Best practices for compliance with individual rights

  Whether auditing and monitoring for all privacy rule rights is conducted separately or as a...

• Scrutinize credit balances to help ensure prompt Medicare repayments

  Your job of ensuring compliance doesn’t end when the facility bills the patient or fiscal...

• GOV’T AUDIT INSIDER: Medicaid payments in excess of Medicare-allowable amounts

  According to an OIG audit report, Medicaid paid providers more than Medicare would have for...

Issue 31, August 10, 2004

• Content of working papers

  A well-developed set of working papers will allow compliance auditors and other officials to use...

• Patient safety: Test staff’s ability to respond to and assess clinical alarms i

  Do your staff know to listen for, and respond to, all of the clinical alarm systems on your patient...

• GOV’T AUDIT INSIDER: Medicaid overpayments go unreported in Colorado

  Colorado Department of Health Care Policy and Financing did not report all Medicaid provider...

Issue 30, August 3, 2004

• Safeguarding of Assets

  Understanding the controls necessary to safeguard assets can help auditors assess the risk of...

• Evaluating physician coding profiles

  To correct faulty processes and optimize your coding and billing practices, evaluate physician...

• GOV’T AUDIT INSIDER: Iowa’s rehab services need stronger internal controls

  Nearly one-third of the amounts claimed by the state of Iowa for its Rehabilitative Treatment...

Issue 29, July 27, 2004

• Documentation compliance plan

  In addition to policies and procedures, HIPAA has provisions related to ducumentation.

• New CMS guidelines clarify EMTALA compliance

  Hospitals now have more information concerning compliance with the Emergency Medical Treatment and...

• GOV’T AUDIT INSIDER: Separate reporting of Medicaid waiver admin costs needed in

  The Centers for Medicare & Medicaid Services requested an audit of the Wisconsin Department of...

Issue 28, July 20, 2004

• View GME/IME audits to ensure accuracy

  Ensure the accuracy of the resident full-time equivalent (FTE) counts that your hospital uses to...

• Safeguarding your organization's goals

  Identifying potential barriers to your organization's success should be your top priority to ensure...

• GOV'T AUDIT INSIDER: Capitation payment proposal inconsistent with BIPA

  PacifiCare used approximately $5.2 million in a manner inconsistent with the Benefits Improvement...

Issue 27, July 13, 2004

• Review OIG and GSA lists for provider exclusions

  Take a look at the Office of Inspector General (OIG) and General Services Administration (GSA...

• Gov’t audit insider: 7/13/2004

  The Ohio Department of Job and Family Services paid $4.6 million in unallowable fee for service...

Issue 26, July 6, 2004

• Understand financial-related audits

  True or false? Are you an expert when it comes to financial-related audits? When you set out to...

• Gov’t audit insider: 7/6/2004

  The state of Tennessee dolled out $5 million to deceased Medicaid beneficiaries, according to an...

Issue 25, June 29, 2004

• Learn the basics of a mammography medical outcomes audit

  All FDA-certified mammography facilities (there are more than 9,000 in the U.S.) must meet auditing...

• Gov’t audit insider: 6/29/2004

  The Alabama Department of Public Health is guilty of not expeditiously and appropriately resolving...

Issue 24, June 22, 2004

• Audit planning: Move outside the paper trail

  A risk assessment isn’t complete without a walkthrough of various patient-care locations.

• Gov’t audit insider: 6/22/04

  The Office of Inspector General (OIG) is cleaning house-and you could be swept into the mess. The...

Issue 23, June 15, 2004

• Gov't audit insider: 6/15/2004

  The OIG recently stepped in to investigate whether incurred costs at James Bell Associates, Inc...

• Handle denied access to records accordingly

  If you are denied access to documents and other forms of evidence that you consider necessary to...

Issue 22, June 8, 2004

• Use audit hours to request additional resources

  If you're feeling squeezed when it comes to having enough time, money, and support for your audits...

• Gov’t audit insider: 6/8/2004

  If your billing and coding department isn't correctly capturing transfers, you could end up...

Issue 21, June 1, 2004

• Ask three questions to kick-off billing and compliance audits

  An important element within your auditing processes is the billing and coding review. This area...

• Ohio nursing homes get a check-up

  Although Ohio is able to identify the skilled nursing facilities (SNFs) that warrant payment...

Issue 20, May 18, 2004

• Reliable data comes from compliant facilities

  Audits provide data that can be used for patient-care research purposes-make sure your audits...

• Gov't audit insider: 5/18/2004

  An audit of administrative costs incurred by the intermediary, TrailBlazer Health Enterprises, LLC...

Issue 19, May 11, 2004

• Quality of care plays an important role in compliance

  Quality care is the cornerstone of an effective compliance program. To ensure quality care for...

• Gov't audit insider: 5/11/04

  Anthem Health Plans of Maine racked up almost $2.8 million in unallowable costs for various claims...

Issue 18, May 4, 2004

• Gov’t audit insider: 5/4/04

  Dublinair Healthcare and Rehabilitation Center in Georgia mixed up its numbers on direct care hours...

• Understand a law's history to protect yourself in the future

  If an allegation of wrongdoing against your facility pertains to a new or untested area of any law...

Issue 17, April 27, 2004

• Fine-tune your working papers

  The working papers you create during an audit should help compliance auditors and other officials...

• Gov’t audit insider: 4/27/04

  The Office of Inspector General (OIG) is taking a fresh look at whether state Medicaid programs are...

Issue 16, April 20, 2004

• Tips on how to avoid criminal liability

  Your organization’s reputation can suffer from allegations of witness tampering in an...

• Gov’t audit insider: 4/20/04

  Iowa didn’t do its homework for records related to accounts receivable (A/R) for overpayments...

Issue 15, April 13, 2004

• Get started on a cost-report audit

  Cost-report fraud is a top government enforcement issue. The many high-publicity financial-fraud...

• Gov’t audit insider: 4/13/04

  Claims submitted to Cahaba regional home health fiscal intermediary came under Office of Inspector...

Issue 14, April 6, 2004

• Determine whether your new-employee policy measures up

  Make sure your hospital’s policy for new employees includes these provisions.

• Gov’t audit insider: 4/6/04

  Iowa must remit more than $650,000 that the state improperly received from Medicare for...

Issue 13, March 30, 2004

• Nurses and ancillary clinicians can help you in the battle for better documentat

  If you demonstrate the value of auditing to nurses and ancillary staff, you can enlist their help...

• Gov’t audit insider: 3/30/04

  Hawaii’s State Children’s Health Insurance Program (SCHIP) improperly reported or...

Issue 12, March 23, 2004

• Internal investigations thrive on open communication

  If you're leading an internal investigation, make sure your team works together to analyze and...

• Gov't audit insider: 3/23/04

  Home healthcare providers often receive reimbursement at unnecessarily high service levels...

Issue 11, March 16, 2004

• Accounting of PHI disclosures

  All patients have a right to see a list of every disclosure their provider has made that included...

• Gov’t audit insider 3/16/04

  Office of Inspector General (OIG) auditors urged Maimonides Medical Center in Brooklyn, New York...

Issue 10, March 9, 2004

• Keep an open mind when auditing

  Even though you have knowledge of the billing or documentation practice of an individual or...

• Gov’t audit insider 3/9/04

  A nursing facility in Georgia that recently underwent an Office of Inspector General (OIG) audit of...

Issue 9, March 2, 2004

• Don't let the Work Plan disrupt your focus

  Don’t just limit your compliance auditing to those issues that the OIG is focusing on in a...

• Gov't audit insider 3/2/2004

  Community Memorial Healthcare (CMH) Hospital, in Marysville Kansas, received the OIG's stamp of...

Issue 8, February 24, 2004

• Use expert opinions in your next audit

  As an auditor or compliance officer, you are often unable to be an expert for all of the operations...

• Gov't audit insider 2/24/04

  Albuquerque Manor Nursing center recently opened its Medicaid cost report to an Office of Inspector...

Issue 7, February 17, 2004

• How to conduct HIPAA-compliant fund raising

  Auditors looking into fundraisers: Make sure all mailings include information on how the recipient...

• Gov't audit insider 2/17/04

  The State of New Jersey is taking heat from the Office of Inspector General (OIG) for submitting...

Issue 6, February 10, 2004

• Use the OIG's evidence-gathering techniques for your next audit

  The Office of Inspector General's (OIG) evidence-gathering rules and techniques could bring...

• Gov't audit insider 2/10/04

  It’s Morton Plant Hospital’s (FL) turn to prove to the Office of Inspector General...

Issue 5, February 3, 2004

• Use publicly available benchmarking tools to enhance the audit process

  You can use the many benchmarking tools that are publicly available to make the audit process as...

• Gov't audit insider 2/03/04

  The Office of Inspector General (OIG) continued its nationwide scrutiny of outpatient cardiac...

Issue 4, January 27, 2004

• Gov't audit insider 1/27/04

  Would your Medicare Secondary Payer (MSP) processes meet the Office of Inspector General’s...

• Determine whether to use in-house or outside counsel

  Use these tips to determine what kind of counsel is best for your facility.

Issue 3, January 20, 2004

• Gov’t audit insider 1/20/03

  Review of outpatient cardiac rehabilitation services at Cooley Dickinson Hospital.

• Review distribution of compliance communications

  Many organizations have trouble demonstrating that they have educated staff and physicians on...

Issue 2, January 13, 2004

• Run reports of data sorted by specific data elements

  Helpful hints for data collection and record abstraction.

• Gov't audit insider 1/13/04

  The OIG’s objective for this review was to determine whether the termination and severance...

Issue 1, January 6, 2004

• Prioritize OPPS audits

  Learn pointers for starting an internal audit.

• Gov't audit insider 1/6/04

  The Office of Inspector General’s (OIG) objective for this audit was to determine the extent...