Note: the following sample auditing and monitoring process is based upon a similar sample we have used throughout this compliance guidance. It is designed to be a sample only, to assist providers in developing their own auditing and monitoring program, and to demonstrate one possible way of thinking about and approaching auditing and monitoring the issue of proper reporting of case mix. We’ve approached auditing and monitoring in this sample as a series of three categories of questions designed to prompt providers to ask key questions that can help avoid and detect potential kickback violations, consisting of the following questions:
- Specifically what are we auditing and monitoring (i.e., what are the specific issues we are looking for in this part of our auditing/monitoring process)?
- What specific sources of information will we examine to find that information (e.g., facility contracts, invoices for services or items purchased, interviews with facility staff and outside contractors, referral patterns and sources, etc.) and specifically, who in the facility or company (by title) will be responsible for each of the individual information source examinations and on what schedule (i.e., how often and when) will they perform these tasks?
- What will we do with the information we obtain as a result of steps 1 – 3, above?
Specifically what are we auditing and monitoring (i.e., what are the specific issues we are looking for in this part of our auditing/monitoring process)?
We are auditing and monitoring for proper assessing, reporting and evaluating resident case mix that result in accurate resident RUG category assignments. Reviews typically focus on MDS accuracy, consistent diagnosis codes and sequence, services documentation, and appropriateness of SNF certifications. Specific issues are medical necessity of the services provided and actual service provision as ordered. The purpose for these reviews is to ensure there is sufficient and accurate clinical documentation that provides underlying support for filed claims, and to verify the accuracy of patient personal information to reduce or eliminate payment delays so that “clean” claims are submitted. RUG assignments unsupported by proper documentation are subject to claim denial and allegations of fraudulent “upcoding”.
What specific sources of information will we examine to find that information and specifically, who in the facility or company (by title) will be responsible for each of the individual information source examinations and on what schedule (i.e., how often and when) will they perform these tasks?
Clinical documentation, including diagnoses, MDS assessments, medical records, are reviewed by the Director of Nursing or designated clinician; therapy logs and therapy services documentation are reviewed by the Director of Rehabilitation or designated therapist; and the Business Officer Manager or designee reviews patient personal information, including, accuracy of name, Medicare number, admission date, and dates of service, and verification of proper SNF certification/recertification. Based upon an evaluation of accuracy and timeliness of previously submitted claims and review/probe history of the provider, the reviews can be performed pre- or post-billing, either 100% of all claims or a representative random sample, again, dependent upon claim history.
What will we do with the information we obtain as a result of steps 1 – 3, above?
The results of the review will be trended and flagged so non-compliant areas can be the basis for pre-claim audits, and can be included in training and education initiatives. Data can be trended over time to detect patterns of exception, and training and education focus can be emphasized.
- The results of the above inquiries will be provided on a regular basis to facility administration and the facility’s Quality Assurance Committee for discussion and revision as needed, with appropriate training or re-training as indicated.
- Applicable policies and procedures on the use and monitoring of psychotropic medications will be revised as needed to address issues and problems in the facility’s use of such medications. Repeat and update the training of staff as appropriate to respond to identified failures in existing policies/procedures and practice.
- As appropriate, the Compliance Officer will discuss the results of these audits with senior management and/or the Board of Directors (or owners) and determine whether any additional measures are required or recommended, whether additional compliance safeguards should be instituted at the facility (including more frequent auditing of applicable procedures), whether training of employees and/or contractors is recommended and such other corrective and monitoring activities are appropriate.