Last month, this column reviewed the benefits of a wound care compliance program and the basic elements needed to develop one. This article addresses policies and procedures, auditing and monitoring, ongoing education and training, internal auditing, and external auditing.
Policies and procedures communicate departmental values and expectations regarding employee behaviors and establish standards for compliance with laws and regulations.
Implementation and Monitoring. Steps include: develop relevant policies and procedures; orient staff members to new and revised policies; periodically review policies and procedures and update to reflect changes in laws, regulations, or processes; monitor departmental adherence to policies and procedures; develop a disciplinary plan regarding nonadherence to policies and procedures; and provide appropriate resources and educational opportunities to staff.
Proactive monitoring and auditing are designed to test and confirm compliance with legal requirements.
Implementation and Monitoring. These steps include: define risk areas and establish need for self-audit; consider your departmental resources for practical auditing; determine subject, method, and frequency of audits; review records such as medical and financial records that support claims for reimbursement; prepare the internal audit report; present findings to applicable parties; develop corrective action plan; and continue ongoing monitoring.
Training should be designed to promote the understanding of internal standards and the requirements of external laws and regulations.
Implementation and Monitoring. Suggested steps include: develop departmental specific educational sessions. (These could include: admitting/registration requirements, documentation requirements, privacy/confidentiality issues, coverage and billing rules, medical necessity, charge entry risks, and coding requirements.); provide sufficient time and resources to staff to attend educational sessions; and document that training and education of staff have occurred.
As a health care provider and a recipient of health insurance dollars, it is important for an organization to conduct internal auditing to prevent improper payments.
Reasons for auditing can include assessing the completeness of a medical record, determining the accuracy of documentation, and discovering lost revenues. When auditing a medical record, the documentation is examined to determine if it adequately substantiates the services billed and identifies medical necessity for the services rendered. If this process is not conducted on an ongoing basis, incorrect, or inappropriate documentation and coding practices, potential risks to the organization, compliance with the organization's policies and procedures, and compliance with payer regulations may not be identified.
Implementation steps for an internal audit include the following: establishing and identifying the need for an internal audit, defining the specific issues of the audit, determining an appropriate sample size, establishing an audit schedule, performing the audit, preparing concise audit report, presenting audit results to applicable personnel, developing action plan, and performing ongoing monitoring.
Periodic external audits should be conducted as part of an organizational compliance audit. This outside audit would confirm internal audit findings and provide any needed corrective actions should inaccuracies be found.
When choosing an outside auditor or consultant, ensure that each audit is conducted by staff that has the knowledge, credentials, and skills necessary for that audit. The chosen auditor/consultant must have expanded knowledge of medical records and documentation based on his or her education, skills, and experience. The audit results should be reported in a professional report that is delivered in a timely manner after the audit/consultation visit. The report should summarize the activities, findings, and recommendations and include concise information to support the determinations made during the audit.
When developing an action plan based on an external audit, it is critical for the provider to identify the regulation or guideline from which the plan was created. In addition, staff must understand the concepts required for the billing and payment of services rendered to help the organization meet its compliance standards. Solutions that may help support an organization's compliance program include: (1) Educating staff on the standards of care approved by the organization. Not all clinicians are able to learn in the same way. (2) Investigating the best method of teaching staff. For example, some physicians and clinicians are visual learners, as opposed to listening to a presentation. (3) Providing the targeted learning experience in creative ways, such as with videotapes, cassette tapes, reading material, verbal presentations, and World Wide Web-architected learning products. (4) Mentoring staff. Discuss realistic goals to achieve after the educational process is complete.
Source: Hess CT. Clinical Guide: Skin & Wound Care. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.