Health Care Auditing and Monitoring Tools Manual
HEALTH CARE AUDITING & MONITORING TOOLS
Second Edition
I. INTRODUCTION
II. WHAT’S NEW
III. COMPLIANCE PROGRAM DOCUMENTS
Job Descriptions
Vice President Positions
Director Positions
Senior Auditor Positions
Compliance Auditor Positions
Internal Auditor Positions
Job Descriptions – University Compliance Positions
Job Description – Vice President of Audit & Compliance
Job Description – Audit and Compliance Analyst
Job Description – Administrator of Audit and Compliance
Due Diligence
Request for Information TMF PEPPER Data and Other Coding Accuracy Information
Request for Information: Copies of Documents Received from Regulatory or Governmental
Agencies
Request for Monthly List of Denied Medicare & Medicaid Claims
Charge Description Master Due Diligence Statement
Employee Education Related to the Reimbursement Cycle: Claims Development, Billing &
Coding Due Diligence Statement
Credit Balance/Refund Due Diligence Statement
Request for Medical Record Coding Internal Audits
Annual Employee Screening
New-Hire Screening Due Diligence Statement
Vendor and Contractor Screening Due Diligence Statement
Physician Due Diligence Checklist
Due Diligence Checklist
IV. RISK ASSESSMENT AND PLAN DEVELOPMENT
General
Suggested Documents for Review of Compliance Program Effectiveness
Compliance Program Effectiveness Review Tool
Compliance Risk Analysis
Office of Compliance Program Evaluation
Risk Assessment Worksheet
HIPAA Audit Risk Assessment
Effectiveness of Medicaid Provider’s Compliance Program: Self-Assessment Tool
Compliance Program Assessment Tool for General Health Care
Fraud, Waste and Abuse Work Plan
HIPAA Risk Analysis
HIT Security Risk Assessment
Compliance Program Risk Assessment: Employee Questionnaire
Compliance Program Risk Assessment: Human Resources Review
Site Credentialing Audit Checklist
Hospitals/Health Systems
Compliance Program Effectiveness Review Survey Questions for Senior Leadership
and Other Key Personnel
Risk Assessment Matrix
Annual Survey for Administrators/Directors/Managers
Compliance Program Objectives Scoring Sheet
Compliance Effectiveness Self-Evaluation – All Elements
Compliance Program Guidance for Hospitals – Checklist
Sample NYOMIG Compliance Program Assessment Status – Overview
Sample NYOMIG Compliance Program Assessment – Detailed Review
Risk Area Review Chart
Proposed Corporate Compliance Annual Workplan
Compliance Effectiveness Assessment and Evaluation
Incident After-Action Report
Physician Practices
Evaluating Conflict-of-Interest Issues in Physician Practice Settings
Behavioral Health
Behavioral Health Evaluation Tool
Long-Term Care
Long Term Care Compliance Risk Assessment
Skilled Nursing Facility – Major Causes of Overpayments Chart
Compliance Program Risk Assessment: Long-Term Care Facilities
Compliance Program Risk Assessment: Long-Term Care Safety Review
Pharmacies
Compliance Program Assessment Tool for Pharmacies
Other
Compliance Program Assessment Tool for Health Care Transportation
V. LAWS AND REGULATIONS REFERENCES
U.S. Laws and Regulations References for Health Care Organizations
VI. POLICIES AND PROCEDURES
Compliance Program/Process
Checklist for Implementation of Policies and Procedures
Policy on Review of Compliance Concerns
Corrective Action Policy and Procedure
Complaint and Appeal Auditing Policy and Procedures
Ethics and Compliance Committee Charter and Procedures
Policy & Procedure Sample: Risk Assessment and Work Plan Development
Auditing and Monitoring Issues
Compliance Auditing and Monitoring Procedure Outline
Internal Audit – Audit Sampling Discussion
Utilization Review Plan Policy and Procedures
Billing/Coding
Compliance Policy: Billing For Services Provided by Non-Physician Practitioners
Billing Audit Policy
Policy and Process Flow Chart for Bill Waiver/Claims Management Related to
Never Events and Adverse Events
Clinical Research
Time and Effort Reporting Policy and Procedures
Clinical Trial Billing Compliance Policy
Conflicts of Interest
Resolution of the Board of Directors Regarding Conflicts of Interest
Policy for Conflict of Interest
Annual Staff Conflict of Interest Disclosure Statement
Annual Conflict of Interest Disclosure Statement – Trustees
Annual Conflict of Interest Disclosure Statement – Board
Contracts
Policy and Procedure for Physician and Clinical Services Contract Management
Policy and Procedure for Non-Clinical Contracts
Fraud and Abuse
Deficit Reduction Act Anti-Fraud Policy
Screening of Federal and State Exclusion Lists
Patient Records
Physician Signature Guidelines
Privacy and Security
Patient Identity Theft (Red Flag) Policy & Procedure
Policy and Procedure for HIPAA and NY State Privacy Breach Notifications
Mobile Device Security Policy
Sample Notice of Privacy Practices
Sample Social Media Policy
Breach Notification Policy Template
Copy & Paste Policy Template
Ransomware Defense Checklist
Ransomware Prevention and Response Checklist
Quality of Care
Quality Management and Improvement Reporting – Policies and Procedures
Stark Law
Potential Referral Source Compensation Methodology, Evaluation and Approval
Reporting Nonmonetary Compensation for Stark Compliance
Other Regulatory Issues
Sample 340b Policy
Insider Trading Policy Template
Opioid Prescriptions for Chronic Pain Patients – Policies/Procedures
Important Message from Medicare – Decision Tree
Medical Device Explants – Procedures for Reporting Credits
VII. EDUCATION AND RE-EDUCATION
Education and Training Process for Hospital Following Voluntary Disclosure
Of Serious Compliance Issue
Coding Compliance Provider Education and Review Program
Compliance Education Tracking Plans
Pre/Post Testing Report for Ongoing/Annual Compliance Training
Compliance Awareness Survey
Hospital System Compliance Training Curricula Assignments
VIII. AUDITING AND MONITORING TOOLS
AUDIT PROCESS
Audit Prep
Audit Budget
Internal Audit -- Planning Memorandum
Internal Audit -- Staff Assignment.
Internal Audit -- Standardized Audit Process Pre-Audit
Internal Audit: Entrance Conference and Planning—Preliminary Meeting
with Management
Checklist for Performance and Documentation of Audits
Compliance Program Project Tool
Auditing & Monitoring Guidelines for Area Office and Service Unit Compliance
Committees Maintaining OIG Compliance
Compliance and Audit Dashboard
Audit Prep Questionnaire – CFO and Controller
Audit Prep Questionnaire – Clinical
Audit Process Checklist
Audit Reporting
Initial Audit Report Format
Follow Up Audit Report Format
Audit Report: PA Prior Approval – Home Health
Correction of Errors Related to Government Reimbursement
Medicare and Medicaid Credit Balances Reporting
Error Correction Provider Notification Form
Self-Audit Report Cover Template
CMS Part C Reporting Requirements Calendar
CMS Part D Reporting Requirements
Audit Committee Dashboard for Compliance
Sample Compliance Committee Meeting Agenda
Multi-System Compliance and Audit Dashboard
Audit Committee Compliance Program Summary
Compliance Committee Report – Annual Summary of Compliance Activities
Facility Annual Compliance Report Template
Audit Report Executive Summary Template
Audit Effectiveness
Audit Effectiveness Checklist
Independent Auditor Effectiveness Evaluation
AUDIT TOPICS
Advanced Beneficiary Notice Issues
Medicare Advanced Beneficiary Notifications Compliance Review
Auditing and Monitoring for Advanced Beneficiary Notices
Advanced Beneficiary Notice Program Checklist for Monitoring Use of ABNs
ABN Process Compliance Task List
Behavioral Health
Partial Hospitalization Audit for Payer Requirements
Psychological Testing Audit Sheet
Psychiatric Diagnostic Evaluation with Medical Services Audit Sheet
Psychiatry Partial Hospitalization Audit Template
Billing and Coding
Evaluation/Management Service Reporting
E/M Documentation Auditors' Worksheet
Internal Audit -- Medicare Services And Supplies Billed Incident To Services
Compliance Review
Internal Audit -- Medicare Diagnostic Testing In Emergency Department
Internal Audit -- Medicare Outlier Payments Review
Internal Audit -- Medicare Excessive Payments For In And Outpatient Services
Compliance Review
Procedure for Filling out Audit Worksheets
Audit Worksheet -- Radiology
Audit Worksheet -- Critical Care
Audit Worksheet -- ED & Observation Care
Audit Worksheet -- Pathology
Procedure for Filling Out Anesthesiology Audit Worksheets
Audit Worksheet -- Anesthesiology.
Audit Worksheet -- Surgery
Procedure Coding of Outpatient and Physician Services
Internal Audit -- Medicare DRG Window Rule (72 Hour Rule) Compliance Review.
Internal Audit -- Medicare Same-day, Same-Provider Acute Care Readmissions.
Internal Audit -- Medicare Secondary Payer Screening Procedures Compliance Review
Review of Disposition/Discharge Codes
IPPE Audit Tool.
Surgery Audit Tool
Dental Chart Review Worksheet
Surgical, Endoscopic/Laproscopic, High Risk or Other Complex Procedures
Psychiatric Partial Hospitalization Audit Program
Internal Audit -- Medicare Inpatient Psychiatric Services
Compliance Monitor -- Discharge Dispositions
Worksheet for E/M Documentation Audit
E&M Audit Tool
Billing for Non-Physician Practitioner Services -- FAQs
Non-Physician Practitioner Decision-Making Flowcharts
Public Provider Reimbursement Internal Control Questionnaire
Shared/Split Visit Audit Checklist
Incident-To Audit Checklist
Patient Services Billing Chart Audit
Audit Worksheet for Teaching Physician Guidelines
System Review Analysis
Detailed Baseline Coding Review.
Coding and Documentation Compliance Review.
Condition Code 44 Checklist.
E M Coding Audit – Orthopedics.
EM Services Hospital Inpatient Initial Care Services – Audit Worksheet
EM Services Subsequent Hospital Care Services – Audit Worksheet.
EPIC Anesthesia Summary Sheet -ICD-10 – Audit Worksheet.
Initial Preventive Physical Examination/Medicare – Audit Worksheet
Annual Wellness Visit/Medicare – Audit Worksheet.
Audit Checklist for Incident To Billing.
Audit Sheet – Inpatient Subsequent Care – General Medicine.
Audit Sheet – Inpatient Subsequent Care – Progress Notes.
Anesthesia Audit Summary Sheet – ICD-10.
Clinical Research
Clinical Trials Planning Memo
Research Cycle Risks
Clinical Research Study Sample Budget
Informed Consent Audit Planning Memo.
Informed Consent Audit Program.
On-Site Audit of Approved Research on Human Subjects
Research Compliance QA Review.
Research-IND Compliance QA Review.
Research-IDE Compliance QA Review.
Research-IDS Pharmacy QA Review.
Clinical Research Compliance Toolkit.
Clinical Research Reflex Testing Protocols Compliance.
Audit Worksheet – Clinical Laboratory.
Conflicts of Interest
Board of Directors Conflict of Interest Disclosure
Questionnaire Regarding Policy on Conflict of Interest and Disclosure of Interests
Contracts and Business Relationships
Independent Contractor Review Audit Program
Timeshare Initiation Checklist.
Joint Venture Compliance Monitoring Checklist
Joint Venture Internal Control Checklist
Physician Contracts Database Audit
Provider Agreements Checklists.
Physician Agreement Compliance – Loan Arrangement Audit.
Provider Based Services Audit: Audit Program and Work Plan
Provider Based Services – Internal Control Questionnaire.
Stark – Physician Transaction Review
Stark – Physician Lease Review.
Medical Director Contract Review Checklist.
Mental Health-Physician Contracts – Audit Template
New Service Start-Up Audit.
Stark – Commercial Reasonableness Checklist.
EMTALA
Internal Audit Program -- EMTALA Compliance Review.
EMTALA Compliance Assessment Questionnaire and Checklist
EMTALA Compliance Review Checklist
HIPAA/HITECH Privacy and Security
Compliance Checklist for HIPAA Omnibus Rule Requirements
HIM Checklist for HIPAA Omnibus Rule Preparation
Compliance Checklist for Business Associates
Safeguarding and Proper Handling of Patient Information
HIPAA Privacy Standards Assessment Questionnaire.
HIPAA Security Monitoring Requirements.
Privacy and Security Audit Tool.
HIPAA Security Rule Evaluation Standard Checklist.
Physician Office Location Compliance Survey Tool
HIPAA Privacy and Security Walk-Through Issues Checklist.
HIPAA Privacy Assessment.
Privacy/Security Monitoring Tool
HIPAA Incident Documentation Checklist
Breach Notification Risk Assessment Log.
Breach Assessment and Decision Tool
Non-Breach Notification Memo Template
HIPAA Breach Log
HIPAA Non-Breach Log.
Security - Corporate Office Walk-Through Checklist
HIPAA/HITECH Patient Privacy Monitoring Form
Privacy/Security Evaluation Remediation Form for Team Leaders.
HIPAA Security Review Checklist
Multiple Entity HIPAA Privacy Assessment
Home Health/Hospice
Official Physician Time Record: Hospice Medical Director
Home Care Outlier Audit Proposal and Audit Forms
Long-Term Care/Skilled Nursing
Rehabilitation Services Chart Review
Long-Term Care Mock Compliance Survey.
Long-Term Care Inspection Checklist: Physical Security of Medical/Dental Records Storage Areas
Skilled Nursing Record Request and Chart Audit Worksheet
Managed Care
Health Plan Vendor Audit Letter Template
Meaningful Use
EHR-Meaningful Use Review
Meaningful Use Audit Program
Meaningful Use Attestation Approval
Other Tools
Voluntary Recalls Review
Internal Audit -- Medicare Bad Debt And Recoveries Program Guide.
Internal Audit -- Adjustments And Write-Offs
Internal Audit -- Medicare Deductible, Coinsurance Calculation and Waiver/Write-Off
Compliance Review
Formal Complaint Audit Tool
Chemoform Clinical Audit Tool
RAC Readiness Assessment Tool
Internal Audit: Fraud Opportunities Checklist
Metric 17 – Pepper Outlier Summary
Metric Pepper Templates
IPPS Two-Midnight Rule Orders Audit Tool
340B Sample Audit Program
340B Retail Self Audit Report for Contract Pharmacy.
Medicare Shared Savings Program ACO Eligibility Requirement Checklist
Medicare Shared Savings Program ACO Compliance Plan
OSHA Hot Topics: Monitoring Form for SNFs and PCHs
ICD Audit Tool.
OSHA Walkthrough Assessment 2017
Permanent Cardiac Pacemakers Audit Tool
340B – Program for Auditing Compliance.
Medical Necessity – Checklist for Cataract Surgery
IX. APPENDICES
Appendix A. Compliance Auditing and Monitoring Articles – HCCA/AHIA
1. Seven Component Framework for Compliance Auditing and Monitoring in Health Care
Organizations
2. Auditing and Monitoring Defined
3. Performing a Compliance Risk Assessment For Compliance Auditing and Monitoring
in Health Care Organizations
4. Developing a Compliance Workplan for Compliance Auditing and Monitoring
in Health Care Organizations
5. Implementing a Core Set of Compliance Policies and Procedures.
6. Compliance Education and Awareness Tools and Techniques
7. Using Computer-Assisted Audit Techniques for More Effective Compliance Auditing
and Monitoring in Health Care Organizations
8. Emphasizing a Documented Comprehensive Approach to Compliance Auditing
