Compliance FAQ | Compliance & Privacy Office

How will a More Focused Risk-Based Auditing Ensure Full-Scale Claim Variations in the Review When a More Open General Audit did Not?

The risk areas identified for review in the remainder of 2021 include codes for surgical cases, office and bedside procedures, diagnostic tests, drugs, E&Ms, modifiers, and/or situations such as telehealth, teaching physician, or known process changes. The audit sample selection will primarily target the specific risk area to be reviewed and the providers involved in that sample will be captured because they used codes or are confirmed to be involved in a particular billing situation. Routine audits targeted a provider at a particular point in time and therefore collected a more random sample based on what that provider happened to be submitting on a given day or week.

Will All Audits and Their Full Workflow Continue to Be Prospectively Handled? Does this Change if a Department's Claims get Outsourced? Will There Still Be Audit QA, and if so, How will Timely Filing Be Ensured?

The plan is to continue to perform prospective reviews whenever possible. The cases outsourced to coding vendors will also be prospective. The QA process will not change. Work queues will be diligently monitored to ensure timely filing. Occasionally, a probe review might be necessary and those will likely be handled retrospectively. These might be in response to a payer inquiry or a report of possible wrongdoing.

Will Any Part of the Transition also Cover Revenue Optimization?

The focus of the billing compliance program is to identify and mitigate billing risks that could be perceived as fraud, waste, or abuse. Audit feedback and ongoing education on billing rules, documentation requirements, and procedure and diagnosis coding are key elements of the compliance program. Proper billing and consistent application of the billing and coding rules result in appropriate reimbursement for services rendered.

How Will Any Re-Audits or Focused Audits Required as Part of Risk-Based Ensure that the Original Problem Areas are Being Evaluated vs. Getting Audited for Something Completely Different?

The goal of any audit program is to mitigate risk. After a risk-based audit is completed for a particular target area, an audit report along with recommended corrective action measures will be issued. Effective implementation of corrective action measures will be confirmed through follow-up reviews. The concept of escalating and scheduled ongoing re-audits and focused reviews no longer applies.