Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency
As a continuation of the 7-Part Blog Series on Compliance, today we will explore Auditing and Monitoring.
- Policies and Procedures
- Reporting and Investigating
- Education and Training
- Prevention and Response
- Auditing and Monitoring
- Responsibility/Oversight of Compliance Officer/Committee
- Enforcement, Discipline and Incentives
Auditing and Monitoring
Auditing and Monitoring are essential controls for detecting, preventing and deterring irregularities in an organization. The intent is to incorporate a system of external reviews to assist in the identification of areas that require improvement while simultaneously ensuring the existing systems are free from error. Auditing and monitoring includes medical record reviews, but, extends to many other aspects of the healthcare business. For example, auditing and monitoring of financial records, employee licensure, HIPAA, and overall compliance of established policies and procedures.
One of the first steps is to distinguish between the two:
Auditing is a more formalized process that requires planning, sampling, testing and validation. Auditing is designed to evaluate and improve the effectiveness of processes and related controls.
Statistics play a role in an audit and these calculations may be the differentiator for governmental payback and self-reporting. Un trained auditors can vastly impact not only the results, but the amount of resources and energy allocated to an unnecessary action plan.
Some key descriptors of auditing include:
- Objectivity: The auditor cannot be biased. Third party, independent reviewers are ideal in these situations. Auditing is governed by professional standards, completed by individuals independent of the process being audited, and normally performed by individuals with one of several acknowledged certifications.
- Formal Report and Communication: The audit must be accompanied by a report inclusive of recommendations for corrective actions and remedies as needed. The findings and plan must be communicated to the board of directors and senior management in a formalized manner on a routine basis.
- Documented Follow-Up: One of the most common flaws with auditing is the identification of an area of improvement without follow up. Every successful organization requires ongoing review of systems to maintain compliance. Supplemental assessments of corrective actions must be documented and communicated to the organization.
- Process: The approach for auditing is structured and systematic. The sample size is defined and the team is mindful of the statistical validity and error rate requirements.
- Subject Matter Experts: It is very important to utilize competent auditors with the skill set relevant to the audit of topic. For example, when an organization is under a Corporate Integrity Agreement (CIA), the government requires an annual audit via an Independent Review Organization (IRO). In these instances, it is critical for the healthcare organization to evaluate whether the specific auditors have the credentials, training and expertise not only with auditing, but with the specific focus at hand. This auditing proficiency requires setting precision (SNF, Acute Care, Home Care, etc.). Seeing that the healthcare organization is financially responsible for the services rendered by the IRO, it is in everyone’s best interest to vet out and qualify all auditors.
Monitoring is a less formalized approach than auditing. It is continuous procedure typically driven by the management team to validate that the implemented processes are effective. Monitoring is useful in detecting areas that require further scrutiny.
Some key descriptors of monitoring include:
- Informal: While the monitoring process may be less structured than auditing, it is not uncommon for auditing techniques to be applied in monitoring situations.
- Auditors: The monitoring process may be completed by Skilled Subject Matter Experts or by the organization’s operations or compliance teams.
- Incorporates checks and balances within multiple systems within the organization. In other words, the system requires more than one method of prevention.
- Periodic: The establishment of a pattern for monitoring, whether it is monthly, weekly or daily is critical for execution.
- Identifier: Monitoring is a methodology for recognizing the need for an audit.
- Responsibility: The management team is ultimately accountable for the implementation of a monitoring system.
- Communication: The existence and findings of a monitoring system must be by department staff and communicated to department management
- Compliance Plan: If monitoring is in relation to the organization’s compliance work plan, this process must be formally reported to Chief Compliance Officer and Compliance Committee
Harmony Healthcare International (HHI) offers a unique approach to Auditing and Monitoring. Our program combines QAPI, Compliance and Medical Record Review into a user-friendly, process refinement methodology. Please call us to hear more about our monthly service plans (Platinum, Gold and Silver) and knowledge center (HarmonyHelp).
As always, I hope this helps with your Quest for Compliance!!
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