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Auditing: Your Check and Balance

Hess, Cathy Thomas BSN, RN, CWOCN

Advances in Skin & Wound Care: September 2012 - Volume 25 - Issue 9 - p 432
doi: 10.1097/01.ASW.0000419410.83064.b4
Departments: Practice Points

Cathy Thomas Hess, BSN, RN, CWOCN, is President and Director of Clinical Operations, Well Care Strategies, Inc (WCS). WCS specializes in focused software solutions, Your TPS® EMR, and mapping best clinical, operational, and technology practices.

Please address correspondence to: Cathy Thomas Hess, BSN, RN, CWOCN, 4080 Deer Run Court, Suite 1114, Harrisburg, PA 17112; e-mail:

Many issues must be addressed to bring wound care practice into compliance with regulations and guidelines set forth by medical health insurance providers. These include development of a compliance program, knowledge of specific health insurance regulations, and education and training.

The development of a compliance program will provide a structure within the organization to monitor and to know and comply with the laws and regulations and policies and procedures related to each individual’s performance.

Proactive monitoring and auditing are designed to test and confirm compliance with legal requirements. Auditing is done to assess the completeness of a medical record, determine the accuracy of documentation, and discover lost revenues. During a medical record audit, 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.

As a healthcare provider and a recipient of health insurance dollars, it is important for your organization to conduct internal auditing to prevent improper payments. Effective compliance auditing includes proactive monitoring and auditing, which will confirm the provider’s compliance with any legal requirements. The auditing function is the check and balance for your documentation:

  • Establish and identify the need for an internal audit.
  • Define the specific issues of the audit.
  • Determine an appropriate sample size.
  • Establish an audit schedule.
  • Perform the audit.
  • Prepare concise audit report.
  • Develop action plan.
  • Perform ongoing monitoring.

 Periodic external audits should be conducted as part of your organizational compliance auditing. This outside audit would confirm your internal audit findings and provide your establishment with any needed corrective actions, should inaccuracies be found.

When an entity chooses an outside auditor or consultant, there are many factors to consider. The audit organization must make sure that each audit is conducted by staff who collectively has the knowledge and skills necessary for that audit. The chosen auditor or consultant must have expanded knowledge of medical records and documentation, based on his/her education, skills, and experience. At a time in the industry when quality of documentation for survey and litigation, coding, confidentiality, and security are emerging as critical issues, it is critical that those chosen to direct your facility have the appropriate credentials.

The audit results should be reported in a professional report that is delivered in a timely manner after the audit or 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, the provider must identify the regulation or guideline from which the plan was created.

Education also should be a focus for all of your staff. When your entire staff understands the concepts required for the billing and payment of services rendered, it becomes much easier for the organization to meet its compliance standards. Remember, the culture of the medical community in each facility is different. In order to blend the skill sets of the clinicians and physicians, a solid, ongoing wound care education program needs to be implemented. A solid program should be coupled with a multidisciplinary team to lead the charge. A strong wound care team strengthens the problem-solving ability of the program.

Educational process is essential to capitalizing on the strengths of your staff. The following list of solutions may assist you in supporting your program:

  • Educate your staff on the standards of care approved by your organization. Not all clinicians are able to learn in the same way.
  • Investigate the best method of teaching your staff, just as you would your patient. For example, some physicians and clinicians are visual learners, as opposed to learning by listening to a presentation.
  • Provide the targeted learning experience in creative ways. Many educational tools exist, including videotapes, cassette tapes, reading material, verbal presentations, and World Wide Web–architected learning products.
  • Mentor your staff. Discuss realistic goals to achieve after the educational process is complete.
  • Educate, reeducate, and support the staff of the facility.

Determining which items and services are covered and how often they are covered can be confusing to all entities asking for reimbursement from healthcare insurers, because of the fact that there is inconsistent coverage among insurers. All providers must understand the coverage policies from insurers.

© 2012 Lippincott Williams & Wilkins, Inc.