Q&A: Establishing a proactive auditing and monitoring plan

Wednesday, September 21, 2022

Q: I work in revenue integrity at a hospital, and almost all auditing responsibilities fall on my department. We’d like to form a committee with members from other departments. Who should we recruit, and what would their role be?

A: Compliance and privacy must collaborate with revenue cycle and revenue integrity professionals to establish a proactive auditing and monitoring plan each fiscal year. This plan would be based on the following:

  • Activity from previous self-audits
  • Activity from previous payer audits
  • Activity within the organization’s state
  • Reviews conducted by the Office of Inspector General (OIG)
  • Audits conducted by the organization’s Medicare Administrative Contractor and state Medicaid agency

It’s best practice for the organization to establish a monthly meeting between revenue integrity, revenue cycle, compliance, and privacy professionals to share plans for auditing and monitoring as well as to go over OIG reviews. The group should review areas in which claims need to be refunded to a specific payer so they can discuss the source of the error and the mitigation plan to ensure that the error does not occur in the future.

Federal guidelines state the organization can take up to six months to quantify an error once discovered. That said, at or before the six-month mark, once quantified, the organization has up to 60 days to refund the appropriate payer. Best practice would be for one individual in the organization to track all of those associated refunds and due dates to be reviewed by the joint revenue cycle, revenue integrity, compliance, and privacy team so that all deadlines can be maintained and reported quarterly to the governing body of the organization.

Compliance and privacy staff will also provide guidance on privacy questions and release of medical record information as situations arise within the revenue cycle.

Editor’s note: This answer is an excerpt from Core Functions of Revenue Integrity, Second Edition.