5I-Sample Auditing Compliance Plan

1 Sample Auditing Compliance Plan (This is a sample only, guidelines should be based on your medical practice, MAC guidelines and Compliance committee) A. Purpose of Audits (Name of Medical Practice) promotes adherence to a Auditing Compliance Program as a major element in the performance evaluation of all providers/NPP documentation. Providers and NPP s are bound to comply, in all official acts and duties, with all applicable laws, rules, regulations, standards of conduct, including, but not limited to laws, rules, regulations, and directives of the federal government and the state of _____, Medicare Contractor, Fiscal Agent (FI) or Carrier (Name of MAC Provider) and rules policies and procedures of (Name of Medical Practice).

2 B. Orientation and Training All new physicians/NPP will receive orientation and training in documentation and Auditing policies and procedures. Failure to participate in required training may result in disciplinary actions, up to and including, termination of employment. Every physician/NPP is asked to sign a statement certifying they have received, read, and understood the contents of the Auditing Compliance plan. C. Education Every physician/NPP will receive periodic training updates in Auditing as they relate to the Auditing process and documentation guidelines. Education will be ongoing based on regulatory changes.

3 It will be mandatory for all providers to attend educational updates. D. Audits/Monitoring Name of Medical Practice auditors will conduct ongoing evaluations of Compliance Auditing processes involving thorough monitoring and regular reporting to the officers of (Name of Medical Practice ) .The (Name of Medical Practice ) develop audit tools designed to address the practice s Auditing Compliance with CPT, HCPCS, and ICD-9-CM coding, billing, CCI and LCD s, claim development and submission, reporting, and documentation. A annual base-line audit will be performed on all providers consisting of 10 health care records per provider.

4 The audits will inquire into Compliance with specific rules and policies that have been the focus of Medicare fiscal intermediaries or carriers as evidenced by the Medicare Fraud Alerts, OIG audits, current year OIG workplans. Audits should also reflect areas of concern that are specific to (Name of Medical Practice ) .The Compliance Officer/Committee shall conduct exit interviews of personnel in order to solicit information concerning potential problems and questionable practices. The audits should identify any patterns and trends in deviations identified by the audit that may indicate a systemic problem.

5 Non- Compliance with the Auditing Compliance plan or violations will result in sanctioning of the involved physician/NPP. Auditors All audits will be performed by certified coders with one or more of the following credentials; (CPC-CPMA, etc). Auditors must complete testing administered by (Name of Medical Practice ) and maintain their credentials. Continuing education is required at a minimum of 10 hours of Auditing CEU s per year. Educational expenses of a maximum of $ per auditor will be paid by (Name of Medical Practice) per year. Proof of continuing education and credentials are required at anniversary hire date.

6 (Name of Medical Practice ) audits are performed (onsite/offsite/hired by another company). All auditors are required to follow the same guidelines dictated in the Compliance plan for Auditing purposes. Auditors employed by (Name of Medical Practice) will be audited by external resources to monitor their accuracy and performance. Auditors must query providers concerning any documentation questions or clarifications. Frequency of Audits Internal audits will be a minimum of 10 audits per provider and conducted on a (monthly/quarterly/semi-annual/annual) basis. They will be selected on (random basis, trending reports, frequency).

7 Audit Error Rate Error rates will be conducted with provider audits and the following is the recommendation for follow-up audits Error Rate Schedule for follow-up audit 10% Annual 20% Eight Months 30% Seven months 40% Six months 50% Five months 60-70% Four months

8 80% Three months 90% Two months 100% One month Auditing Reports Physicians will received a written report following each audit performed.

9 The following information will be included in each report: a. Patient name/date of service b. Provider name c. Level billed/level documentation supports d. Diagnosis codes billed/diagnosis documentation supports e. Any coding/billing discrepancies f. Medical necessity g. Recommendations/concerns h. Auditor name The provider can contact the auditor for discussion/questions concerning their audits. Reports will be sent to Compliance officer and medical director for review. E. Non-Compliant Physicians/NPP/Auditors When disciplinary action is warranted, it should be prompt and imposed according to written standards of disciplinary action.

10 The following action will include, without limitation, one or more of the following: a. Additional education/training b. Verbal counseling c. Pre-payment audits Continuous violations will be reported to the Medical Director of (Name of Medical Practice ) within 30 working days after receipt of an investigative report. The Medical Director shall determine the action to be taken upon the matter of Reduction, suspension, or revocation of clinical privileges. a. Reduction, suspension, or revocation of clinical privileges b. Suspension or termination of employment. The Medical Director of (Name of Medical Practice ) shall have the authority to, at any time, suspend summarily the involved provider s clinical privileges or to summarily impose consultation, concurrent review, proctoring, or other conditions or restrictions on the assigned clinical duties of the involved provider in order to reduce the substantial likelihood of documentation and Auditing violations.