Corporate Compliance

1. Determine the scope of your internal investigation
2. Fraud settlement prompted facility to add more audits and reviews
3. Gov't audit insider

Healthcare Auditing Weekly, August 19, 2003

Health Care Auditing Strategies
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Guide to Compliance Auditing: Applying OIG Techniques and Tools
Strategies for Health Care Compliance
August 19, 2003
Vol. 1, No. 16

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In This Week's Issue

  1. Determine the scope of your internal investigation
  2. Fraud settlement prompted facility to add more audits and reviews
  3. Gov't audit insider

This Week's Headlines

1. Determine the scope of your internal investigation

The scope of your internal investigation depends on what prompts it. Use the following guidelines to determine the scope of an internal investigation:

1. What kind of issues the investigation raised. Develop a list of issues that you think in-counselors should know about, so they can help you determine whether to conduct the internal investigation. Include a range of issues, especially those that involve violation of health care statutes and regulations, such as submissions of fraudulent billing, false claims, upcoding, kickbacks, and overpayments.

2. How the problem arose. If the government has started investigating your organization, your internal investigation should shadow the government's every move. Find out the subject of the government's investigation by interviewing employees the government has contacted, contacting the lead investigator, interviewing key employees, and reviewing important documents before the government reviews them.

The following factors also affect the scope of your internal investigations:

  • The number of persons or business units involved in the misconduct
  • The extent to which mid-level and senior management was involved in the misconduct
  • The length of time over which the misconduct occurred
  • Whether the misconduct affected any government-related services or enforcement efforts
  • Whether the misconduct was prohibited under the company's compliance program
  • Whether a civil lawsuit will likely follow
  • Whether the issue is limited to a human resource problem
  • Whether there is likely to be adverse publicity

    For more information on how to conduct an internal investigation, order the book "See for Yourself: A Guide to Conducting Internal Investigations and Audits." This book will show you how to conduct your own internal investigations and audits from start to finish. It offers practical advice and real-life examples on how to plan and staff an internal investigation or audit, and provides detailed information on the legal issues involved, such as attorney/client privilege, obstruction of justice, and legal obligation to disclose results. Click here to order.

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    Coding audit training for HIM managers

    HIM managers can learn to audit coding in different health care settings with the CD audio set "Coding Lunch & Learn for Managers: Auditing ALL Types of Coding," from HP3 and HCPro. The set includes two 75-minute audio CDs and one workbook CD (complete with printable documents, references, actual physician documentation, and medical records scenarios to code), developed by Ruthann Russo, JD, MPH, RHIT, and CEO of HP3. It can be used for acute care settings, clinics, physician services, skilled nursing, rehabilitation, home health, and hospice care. Best of all, you earn valuable continuing education credits with this and every "Coding Lunch & Learn" package.

    For more information or to purchase, click here, or call our Customer Service team at 800/650-6787. Mention Source Code EZ22610A when you call.

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    In addition to each 12-page monthly newsletter, Health Care Auditing Strategies (HCAS) subscribers receive the following benefits:

  • Audit talk-This is a free forum to network, share ideas, and solve problems for HCAS subscribers.

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  • Editorial special reports-When there's a new regulation or news on laws related to health care auditors, our expert writers gather the necessary information and compile a special report. Subscribers received a free special report on the Sarbanes-Oxley Act with their May issues.

    Take advantage of these subscriber benefits, as well as auditing best practices and how-to articles by subscribing to Health Care Auditing Strategies. Save 10% by ordering online.

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    2. Pay-Per-View article: Fraud settlement prompted facility to add more audits and reviews

    It was 2001, and four medical schools in the University of California (UC) Health System settled with the government for $22.5 million. The settlement came as a result of a Department of Justice (DOJ) audit of physicians at teaching hospitals, or PATH. At the time, administrators there knew that more comprehensive coding compliance audits were in order.

    Go to "Fraud settlement prompted facility to add more audits and reviews" for the rest of this article. The cost is $10. Subscribers to the online version of Health Care Auditing Strategies have free access to this article. Subscribers to the print edition can find it in their August issues.

    Or for only $23 per month, you can get even more auditing best practices and how-to articles by subscribing to Health Care Auditing Strategies. Save 10% by ordering online.

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    Network with your audit colleagues

    "Audit Talk" is a new, moderated chat forum that members can use to post messages or questions for their peers 24-hours-a-day. "Audit Talk" offers a free forum to network, share ideas, and solve problems for those in the audit industry. Getting involved is easy. To subscribe, just send your request to this e-mail:

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    Medicaid drug rebates

    The OIG's audit objective was to evaluate whether the Alabama Medicaid Agency (AMA) had established adequate accountability and internal controls over the Medicaid drug rebate program. The OIG used the following methodology:

    1. Interviewed AMA officials to determine the policies, procedures, and controls that existed with regard to the Medicaid drug rebate program.

    2. Interviewed staff members to determine their roles in the drug rebate program.

    3. Obtained and reviewed drug rebate accounts receivable records and compared data to the Form CMS 64.9R report for June 30, 2002.

    Click here to read the OIG audit report "Audit of the Medicaid Drug Rebate Program in the State of Alabama."

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    To learn more about the Sarbanes-Oxley Act and how it affects internal auditors and compliance officers, order the special report "Sarbanes-Oxley Act: Impact on Health Care Organizations."

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