COLUMBIA/HCA

DEPARTMENT: Governmental Operations Support / Billing Compliance Support / POLICY DESCRIPTION: BILLING - Audit & Monitoring
PAGE:1 of 2 / REPLACES POLICY DATED: January 16, 1998
APPROVED: February 25, 1999 / RETIRED:
EFFECTIVE DATE: March 1, 1999 / REFERENCE NUMBER: GOS.GEN.001
SCOPE:
Business Office Nursing
Admitting Ancillary Services
Finance Health Information Management
Administration Utilization Review
Revenue Integrity
PURPOSE: To ensure an effective audit and monitoring process has been established for each billing policy and procedure.
POLICY: In order to ensure compliance with billing policies and procedures a facility billing audit committee will be established. The committee’s structure, objectives, and required documentation are as follows:
1. STRUCTURE
The Facility Ethics and Compliance Officer (ECO) must establish a Facility Billing Compliance Audit Committee with the following members:
a)Chief Financial Officer
b)Business Office Director
c)Ancillary Department Director (e.g., Laboratory Director)
d)Health Information Management Director
e)Physician Advisor
f)Other individuals as deemed appropriate (e.g., Admitting Supervisor, Billing Supervisor, Revenue Integrity, Utilization Review).
2. OBJECTIVES
The Facility Billing Compliance Committee will meet on a monthly basis and perform the following:
a)Audit each policy and procedure in accordance with the Audit Tool and Instructions or as specified in each policy.
b)For those policies in which a random sample selection is required, utilize the Random Sampling Instructions document (Attachment B).
Prepare an Action Worksheet each month (see Attachment A). For each policy in which an error was present, the root cause of the error (e.g., masterfile/dictionary issues and/or process issues) must be identified and addressed. If the error appears to be isolated to one given account, then that account should be rebilled appropriately. If the error suggests the possibility of other similar errors, a further analysis should be conducted with regards to bills issued on or after the implementation date of the policy. Any erroneous bills should be rebilled from the date the specific billing policy was implemented. Accounts with errors prior to the date of the specific billing policy implementation should not be rebilled as they will be addressed as part of the national investigation. Any errors noted which relate to accounts prior to policy implementation should not be investigated by the facility but instead must be reported to your facility Operations Counsel for review.
c)As error rates are reduced to 0% for each policy which is audited on a monthly basis, the sample size of the audit function may be reduced in accordance with the Random Sampling Instructions.
3. DOCUMENTATION
The Audit Committee must clearly document at a minimum the following elements: date, attendees, testing performed with the Audit Tools, Error Rates, Action Taken, Status of Action in place, etc.
It is the responsibility of the Ethics and Compliance Officer (ECO) to ensure adherence to the procedure.
REFERENCES:
OIG Model Compliance Plan for Clinical Labs (March, 1997), Federal Register Vol. 62, No. 41
The Office of Inspector General’s Compliance Program Guidance For Clinical Laboratories (August 1998) pgs. 27-28

03/01/1999

ATTACHMENT A

BILLING AUDIT ACTION WORKSHEET

DATE:______

ATTENDEES:______

Policy & Procedure Description / Error Rate(s) / Issue / Action to be Taken / Responsible Party / Timeframe / Status / Comments

Attachment to GOS.GEN.001

ATTACHMENT B

Billing Policy Compliance

Random Sampling Instructions

To ensure appropriate sampling techniques are performed to monitor each billing policy, the following procedures must be utilized to select each sample. The sample sizes and selection process outlined in these instructions will not yield statistically valid samples for a given month, at a given facility. However, over time, this process will provide valid statistical data to analyze the population. Samples should be selected and documented as follows:

  1. Maintain daily system reports of registration activity preferably to include the patient name, patient number, patient type, financial class, and type of service for ease of sample selection (e.g., Registration Activity Report (Bill:Bill09) if using the Patient Accounting System) in a central location, in date order, and by month. Retention and central control over these reports will help ensure proper random sampling techniques can be performed and documented as outlined below.
  1. By the end of each subsequent month (starting 30-45 days after the policy is implemented), select a sample of 15 accounts foreach policy from the “Registration Activity Report”. NOTE: the accounts may be used for all applicable policies, to the extent possible. If no errors are noted for a given policy, the sample size may be reduced to 5 in the subsequent months. If any errors are noted, the subsequent month’s sample should be 15. The samples must be selected as follows:

a)Count the number of pages for the registration activity reports accumulated for the month under review.

b)To determine what page to begin the sample selection on, divide the total number of pages by the sample size. For example, if the reports for the month of February consisted of 90 pages and the sample size is 15, divide 90 by 15 to arrive at a value of 6. (If sample sizes of 15 and 5 will both be used (for different policies), 15 should be considered the “sample size” for all policies even though only 5 may be selected for testing.) When dividing the sample size by the total number of pages, if the result is not a “whole” number, then round up to the next number for .5 and greater and round down for less than .5.

c)Select an account from each identified page in b) above (e.g., select an account from every 6th page of the “Registration Activity Report” per the above example) as follows:

  • Assume each month under review has been assigned the corresponding number for that month: January = 1, February = 2 … December = 12. Select an account on each identified page in b) above which corresponds with the number assigned to the month under review. For example, if the month under review is February, select and highlight the second account on each identified page.
  • For each account selected, determine if the account meets the following criteria by reviewing the charge detail on the on-line patient accounting system:

The payor present on the account is a federally funded payor for which this billing policy applies.

The account includes Laboratory services/procedures for the procedures under review.

Patient type is “Outpatient” (including Emergency Room, Same Day Surgery, Observation, etc.).

  • If the account selected does not meet the above criteria, select the next account on the page and determine if the criteria are met. Continue this process until an account is located which meets the above criteria and an account has been selected for each procedure under review. If you reach the bottom of the page, and the account sample is not complete, continue the same process on the next page. (Note: The same account may be used for multiple policies to the extent possible).

Example:

Assume the month is February and the total pages are 90. The sample selection would start on page 6 (90 pages divided by a sample size of 15).

If the second account on the report (February = 2) does not meet the defined criteria above, for example, the payor class was commercial, proceed to the next account.

Assume the next account meets the defined criteria and includes a venipuncture and a CBC procedure. Document the account on both the Outpatient Specimen Collection and Hematology worksheets.

Proceed to the next account and continue this process until one account has been identified for each procedure being audited.

Proceed to the 12th page of the report and select the second account in the sample for each policy following the same process.

Continue this process until a sample of 15 is selected for each policy.

  • Log each account on the applicable “Audit Worksheet” ensuring the appropriate sample size is logged for each policy.
  1. Clearly document the sample selection process each month and maintain this documentation as an audit trail.

Page 1

Attachment to GOS.GEN.001

Attachment B - Automated

Billing Compliance Policy (GOS.GEN.001)

Automated Random Sampling Instructions

Revised December 15, 1998

For Use with Meditech/PA and Meditech B/AR Systems

The Random Sampling Report can be used by Meditech/PA or Meditech B/AR facilities to generate a list of randomly sampled accounts for purposes of auditing the Laboratory Billing policies and procedures. To ensure appropriate sampling techniques are performed to monitor each billing policy, the following report can be utilized to select each sample. Refer to the Audit and Monitoring policy (GOS.GEN.001) for more information. For facilities not using Meditech/PA or Meditech B/AR, follow the Manual Random Sampling Instructions – Attachment B Manual.

This report can only pull information that is 45 days old or less, so it is very important that the report be printed on a monthly basis, preferably before the 15th of each month.

The following includes step-by-step instructions on how to setup and run the Automated Random Sampling report, and how to select the sample:

System Setup

  1. Make sure that your IS department has placed the NPR report titled “Sample of Patients – Outpatient Lab Federally Funded” on your CPCS Lab Module menu.
  1. The Zlink is as follows: Z.link.to.other(Q("EXT.PROD","LAB.L.SPEC.zz.op.sample.link"))

Run Report

  1. Prior to the 15th of each month, run the NPR report. The report can be found on your CPCS system under the title “Sample of Patients – Outpatient Lab Federally Funded.”

/ Your screen should look like this. You will be prompted for the following information:
  • From Date
  • Thru Date
  • Facility
  • Financial Classes
  • Sample Size
  • Printer Device

2.Enter the From and the Thru Dates. (Note: this report can only pull information that is 45 days old or less.)

/

The From and Thru Dates must be input in the format of MM/DD/YY as shown on this “look-up” field. The monthly audits should have a From Date and Thru Date of the first and the last day of the 30-day period being audited.

3.Select your facility.

/ At the facility prompt, you may use the “look-up” function to pull up the list of facilities. Then select the number that corresponds to your facility. In this example, Hillside Hospital would type 7 [enter].

4.Select the financial classes that you want to sample.

/ Your random audit sample should include all federally-funded financial classes. Select all the financial classes used at your facility which are categorized as “federally-funded.” You may select as many choices as you need in this screen.

5.Select the sample size needed for your audit.

/ The sample size for any given month is based on the results of the previous month’s audit. If you succeeded at reaching 0% errors on the previous month’s audits, then you can select the sample size of 5. If there were any errors (greater than 0%) noted in the previous month’s audit, then you would select the sample size of 15.

6.Select the printer device to print out the random sampling report.

/ The “Print on” prompt requires an active printer device be typed or selected from a lookup screen. This report can be easily printed on a laser-style printer.

7. Use the printed report to select random accounts for the audit. Refer to the sample report shown below.

Run Date: 4/27/98HOSPITAL Z **ADMISSIONS** Page 1

Run Time: 0856Sample of Patients – Outpatient Lab Federally Funded

Dates: 04/01/98 – 04/30/98

Account # / MR# / Name / Svc Date / Fin Class / Status
M00102594618 / C002345672 / Smith, Sue / 4/2/98 / 01 / RCR
M00102590123 / C002345679 / Jones, John / 4/22/98 / 01 / RCR
M00102594644 / C002346820 / Zeus, Jen / 4/28/98 / 03 / CLI
M00102622111 / C002346172 / Ball, Lynn / 4/15/88 / 02 / SDC
M00102534444 / C002348911 / * Stone, Cheryl / 4/4/98 / 03 / CLI
M00102534567 / C002347692 / Morton, Lara / 4/12/98 / 06 / CLI
M00102560234 / C002344974 / Brown, Lilly / 4/30/98 / 01 / RCR
M00102599377 / C002343888 / Reed, Donna / 4/25/98 / 03 / RCR
M00102600011 / C002344673 / Anderson, Joe / 4/2/98 / 01 / ER

The report will show all accounts that had any lab orders placed through the Order Entry module within the specified time window for the financial classes selected. All outpatient account types will be included, as well as Observation patients. Recurring outpatients will be included on the report once per service date.

Notice that the asterisk in front of the name points out the account where you should begin looking for a match to your audit procedures. For each account selected, determine if the account meets the criteria for the laboratory procedures under review. In this example you would look up account M00102534444 Stone, Cheryl on your Patient Accounting system to see if the patient had any of the audited procedures, such as: CBC, Urinalysis, venipuncture, etc.

  1. If the account meets the audit criteria, then log the account on the applicable “Audit Worksheet(s).” Proceed to the next account and continue this process until one account has been identified for each policy being audited. Then move to the next asterisk mark on your automated random sampling report to get the second round of accounts and so on. Continue in this manner until you have obtained your sample size for each of the policies being audited. (Note: there may be some policies that require sample size of 15 while others may only require 5.)
  1. Clearly document the sample selection process each month and maintain this documentation as an audit trail.

Attachment to GOS.GEN.001