Our text discusses three types of audits performed in the administration of a medical office: external, internal, and accreditation.
There are four main reasons these audits are performed; to access the completeness of the medical record, check the accuracy of the medical documentation, uncover lost revenue, ensure compliance with all HIPAA regulations.
External audits are an investigative review of selected records performed by a private payer or government agency (Medicare, Medicaid). Account records may be reviewed as well as code linkage, completeness of the documentation and the observance of documentation standards i.e. signing and dating entries by the healthcare professional.
There are two types of audits that third-party payers perform
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Particular attention is focused on evaluation and management codes to ensure their correct use. Internal audits should be performed as part of the office routine and not just when suspicious or fraudulent behavior is detected. This is the best way to reduce the chance for an investigation and to prevent employees from having to become whistleblowers.
Internal audits are necessary to determine if procedures are being coded accurately based on the documentation. They also help evaluate a coders knowledge and skill and provide feedback to the practice as to the need for training or review of the compliance plan and policies. Audits are also beneficial in determining the physician’s involvement/communication with the billing staff, coders and the insurance specialist.
Internal audits can either be prospective or retrospective. Prospective audits are done before the claim is submitted and usually only performed on claims like workman’s compensation, as it is difficult to perform the audit without all the documentation available. Retrospective audits occur after payment when all the necessary documentation can be
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But should you be fearful of audits? AHIMA suggests that HIM professionals use audits to propel their coders and other staff to greater efficiency and accuracy. Keeping a positive view of audits and using them as a tool to discover areas of weakness and strengths is important. One HIM professional suggests that “external coding audits be positioned as an educational benefit for coders and a tool to boost their confidence” and other HIM experts adds that “audits have helped him target continuing education investments for each coder and set individual performance goals, which have become part of annual employee evaluations.” (Brownfield & Didier,
How would you like to keep track of your personal health information record in your computer at home? The electronic data exchange was one of the goals of the government to improve the delivery and competence of the U.S. healthcare system. To achieve this plan, the U.S. Congress passed a regulation that will direct its implementation. The Department of Health and Human Services is the branch of the government that was assigned to oversee the HIPAA rules. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is a national public law in the United States that was created to improve health insurability, prevent insurance abuse and to protect the privacy and security of a person’s health information.
In the United States, healthcare fraud and abuse are significant factor associated with increasing health care costs. It is estimated that federal government spends billions of dollars on the health care cost (Edwards & DeHaven, 2009). Despite the seriousness of fraud and abuse offenses, increasing numbers of healthcare providers are seeking new and more profitable ways to build business relationships. These relationships include hospital mergers, hospital-physician joint ventures, and different types of hospital-affiliated physician networks to cover the rising cost of health care (Showalter, 2007, p 111-114). When these types of arrangements are made, legal issues surrounding the relationship often raise. There are five important Federal fraud and abuse laws that apply to the relationship and to physicians are the False Claims Act (FCA), the Anti-Kickback Statute (AKS), the Physician Self-Referral Law (Stark law), the Exclusion Authorities, and the Civil Monetary Penalties Law (CMPL) and (Office of Inspector General (OIG), 2010). Out of five most important laws that apply to the relationship and the physicians, we are going to focus on the Anti-Kickback Statute (AKS) and the Physician Self-Referral Law (Stark law).
Module two deals with external influences in healthcare administration and the conflicts that may cause lack of growth in the organization. External influences can range from society, stakeholders, staff, and patients. Health administrators should be in agreement with staff and physicians to maintain proper ethics and safety for everyone. Society has a big influence of healthcare organizations with spending their money towards health insurance, medication, treatment services and exams. As long the healthcare organization has a well reputation built on trust, then consumers will spend on that healthcare organization. The stakeholders that take part in external influences on ethics are the vendors, technology specialists, maintenance, insurance
HIPAA and fraud & abuse tie together in the way HIPAA protects the use the PHI in the billing and coding of claim form. No matter if the patient sells their information, HIPAA is there to help protect against fraud and abuse. One way HIPAA helps prevent fraud and abuse is in the case of preforming an audit. Although the government is the top payer in the US. Payers are the ones who do the audit of the offices. They make sure that what is on the claim matches what is on the patient’s record. This is how fraud and abuse can be stopped from continuing on.
I had the opportunity to meet with Dee Laguerra for a few hours and learned so much about the Medical records side of our facility and its impact on healthcare organization. As Director of Health Information Management (HIM) she is responsible for many aspects of managing the medical record; which is a legal document. I did not realize how complex this department is and how vital this department is to the legal and financial position of the organization. Dee’s position as director is the responsibility for the collection, organizing, scanning, and completions of the medical records in a timely matter after the patient is discharged. The reason for the timeliness of scanning the medical records is for the preparation for the coders to review all the charts to code for insurance billing. The time requirement for th...
this will cause healthcare providers with the training and education needed for clinical documentation improvements to be installed effectively. It is important that having a specialized team who can create solutions towards Clinical Documentation Improvement (CDI) in order to minimize the failures that may occur. In this case, investing in training for the materials/tools necessary for healthcare providers to excel in their work with CDI. Essentially, Clinical Documentation is used throughout the healthcare system for the analysis of care, communication, and medical records. This is important because the information of medical records that healthcare providers are able to access, will help patients track their health conditions. Thus, clinical documentation improvement has a direct impact on patients by providing quality information. On the other hand, the new technological advancements will also be able to address the efficiencies in health care system that differ from paper-based charting. Improving on the quality of information will also have the effect upon the ethical and effectiveness of care that is being provided. This has a significant impact in order to maintain patient care that ensures the documentation is accurate, timely, and reflect within the services provided. Documentation assessments can be utilized so there can be improvements on the education for healthcare providers as they intend implementation standards take effect immediately. In this case, failures must be analyzed so that they will have the ability to comprehend and determine an organization’s strengths and weaknesses
Objectivity also needs to be evaluated to make sure the internal audit is reliable. The internal audit needs to be free of conflicting responsibilities as well
HIPAA provides the first federal protection for the privacy of medical records (Burke & Weill, 2005). HIPPA encourages the use of electronic medical records and the sharing of medical records between healthcare providers, because it can aid in saving lives. HIPAA requires that patients have some knowledge of the use of their medical records and must be notified in writing of their providers' privacy policies. HIPAA has technical requirements that a healthcare provider, insurer, or service provider, unless exempt under state law, must provide. An organization must conduct a self-evaluation to learn what threats its records face, and develop techniques needed to protect the information (HIPAA, 1996).
Throughout this paper I will explain what HIPAA is, examples of violations employee’s make and how they are penalized for the violations. What is HIPAA? The Health Insurance Portability and Accountability Act was enacted in the year of
According to the report provided by the consultant, the employees at this facility were not taking precautions in safeguarding the patient’s health information. Therefore, the employees at this facility were in violation of the Health Insurance Portability and Accountability Act (HIPPA). It is important for employees to understand the form of technology being used and the precautions they must take to safeguard patient information.
The seven best practices in the roles and responsibilities of an internal audit function include:
The part of the unit known as the internal affairs department is under the inspection unit section. The main job of an internal affairs investigator entails keeping a close eye on department’s policies and procedures by conducting “internal quality control inspections” (Dempsey, Frost, & Carter, 2014) (p. 99). Other duties that one must consider when working in this area of the unit according to (Dempsey, Frost, & Carter, 2014) is to focus on suspected “misconduct and corruption of other officers” (p. 99). They must ensure that all employees within the department are adhering to the rules and conducting themselves in the manner that the system, guidelines and policies requires. Another main objective that the internal affairs division has is to uphold the integrity of the department. In fact, according to (Dempsey, Frost, & Carter, 2014), “they are the police that police the department” (p. 247).They do so by making any improvements and putting new practices into practice and making sure officers are abiding in those protocols and
The Health and Human Services (HHS) settled a case with Blue Cross Blue Shield of Tennessee (BCBST) for $1.5 million for violating the Health Insurance Portability and Accountability Act (HIPAA) and security rules. There are security issues with BCBST in regard to confidentiality, integrity, availability, and privacy. There are also security requirement by HIPAA which could have prevent the security issue if it has been enforced. There are correction actions taken by BCBST which were efficient and some may have not been adequate. There are HIPAA security requirements and safeguards organization need to implement to mitigate the security risk in terms of administrative, technical, and physical safeguards.
This built in audit will allow for coders to correct entries immediately and lessen the scope creep associated with re-entry at a later time; this will lead to an increase in productivity and accuracy within the department. In addition, the data analyst should consider increasing the frequency coding audits from quarterly to weekly until the outcomes of these audits improve. Also, the organization should consider the ‘need to implement an assessment plan to review the data collected such as “reabstraction studies
Auditing has been the backbone of the complicated business world and has always changed with the times. As the business world grew strong, auditors’ roles grew more important. The auditors’ job became more difficult as the accounting principles changed. It also became easier with the use of internal controls, which introduced the need for testing, not a complete audit. Scandals and stock market crashes made auditors aware of deficiencies in auditing, and the auditing community was always quick to fix those deficiencies. Computers played an important role of changing the way audits were performed and also brought along some difficulties.