HCCA 2006 Compliance Institute April 25, 2006

Transcription

1 Case Study: Building and Operating an Integrated Compliance and Internal Audit Department HCCA 2006 Compliance Institute April 25, 2006 Heidi Crosby CPA, CIA Director, Audit Services Trinity Health Michael Holper CPA, CIA, CHC VP, Org. Integrity & Audit Services Trinity Health James Knauf RT(R), CHC Director, Org. Integrity Trinity Health 1

2 Overview Introductions and Background Comparing and Contrasting Compliance and Internal Audit Roles and Responsibilities in Trinity Health Benefits of Integrated Compliance and Internal Audit Challenges in Integrating Compliance and Internal Audit Case Studies Concluding Remarks and Q and A 2

3 Source: Trinity Health 2005 Annual Report Created in th largest Catholic health system in U.S. 45,000 FTEs and 7,300 physicians 44 hospitals (29 owned, 15 managed) 379 outpatient clinics/ facilities Long-term care, home health, hospice services Operations in 7 states Revenues of $5.7 billion $401 million in community benefits 3

4 Comments About Trinity Health Historically, de-centralized operations with few centrally administered and managed functions at Home Office Since merger in 2000, movement towards more consistency and standardization in areas such as information systems, supply chain, insurance and risk, major capital projects, etc. Accelerated efforts to develop consistent standards and practices in areas such as clinical operations and revenue management are planned for the future 4

5 Organizational Integrity Program Local Integrity Officers 23 Ministry Organizations Responsible for implementation and operation of the OIP within their Ministry Organization Member of senior staff with direct reporting to CEO Provides regular reports to local CEO and Board on OIP Participates as a member of Organizational Integrity Council Local Integrity Committees (LInC) Assists LIO in implementation and operation of OIP within Member Organization Chaired by LIO Trinity Health Organizational Integrity Council (OIC) Ministry Organization LIOs, Home Office OI Management, Legal, Mission and Ethics Meets quarterly 5

6 Compliance and Internal Audit Reporting Organizational Integrity Corporate Committee CEO, President - H&HNs, CFO & General Counsel Trinity Health President & CEO Vice President OI & Audit Services Trinity Health OI & Audit Committee of Board of Directors Director Audit Services Director Organizational Integrity Director HIPAA Privacy 18 Financial/operational auditors 5 Information systems auditors 4 HIM/coding, medical necessity for facility services 3 Coding for professional/physician services 2 Patient financial services/cdm 2 Post-acute care services 1 Hotline, education coordination, other program support 6

7 Comparing and Contrasting OIAS Staff Backgrounds And Experience Organizational Integrity Health care operations experience Clinical (nursing and ancillary) HIM/coding UR PFS CDM physician practice, post-acute care RN, RHIA, RHIT, CCS, RTR, CHC Audit Services Financial and information systems audit training and experience Majority with prior public accounting and/or auditing experience CPA,CIA,CISA certifications 7

8 Comparing and Contrasting OIAS Responsibilities Organizational Integrity Perform regulatory compliance and other types of audits requiring clinical, coding and operations training and experience Perform special investigations and consult on repayment situations/disclosures In addition to audits, provide support to LIO to ensure other elements of Trinity Health s OIP are effectively integrated within local operations Audit Services Perform financial, compliance, operational and information system audits requiring financial and/or IS audit training and experience Perform special investigations and forensic audits Provide direct assistance to external auditors in performance of Trinity Health s annual financial statement audit 8

9 Comparing and Contrasting OIAS Subject Matter Experts vs. Generalists Organizational Integrity Serve all Trinity Health organizations Each OI manager and their team are subject matter experts (SME) in their particular areas Responsible for annual Work Plan development in subject matter areas including: Risk assessment Audits Education Other Audit Services Serve all Trinity Health organizations Each AS manager and their team assigned to specific TH organizations for relationships and annual work plan Areas subject to audit much broader - requires more generalist background for staff Manager and senior auditors function as SME teams 9

10 Comparing and Contrasting OIAS Additional Roles Organizational Integrity Liaison to Home Office work groups HIM Council Quality/Patient Safety Informed Consent Project Genesis (EHR) Insurance and Risk Management Legal Audit Services Liaison to Home Office work groups Trinity Information Services Capital Project Management Supply Chain Management Revenue Management Finance/Treasury Enterprise Information Security 10

11 Benefits of Integrated Compliance and Internal Audit Department Governance oversight and reporting Single board committee Combined committee charter reflecting both internal audit and compliance program oversight Overlap of compliance and internal audit functions scope and responsibilities Combined department charter Independence from operations Risk assessment requirements Auditing requirements Planning, fieldwork, reporting, action plans, follow-up 11

12 Auditing and Monitoring Status Today 84% of compliance officers reported auditing and monitoring programs as the #1 significant goal for their compliance programs during the next 3 years Auditing and monitoring has consistently been reported as one of the top 3 goals since 1999 Source: HCCA 7 th Annual Survey: 2005 Profile of Health Care Compliance Officers 12

13 Auditing Resources Historically, many health care organizations have lacked fully-developed internal audit functions Where internal audit functions exist, resources may have been financially focused Lacking clinical, coding and operations experience needed for compliance programs Integrated department has assisted in ensuring appropriate mix of skills and experience of staff Integrated department has also assisted in ensuring appropriate audit resources are assigned to support compliance program 13

14 Benefits of Integrated Compliance and Internal Audit Department Coordinated annual risk assessment and work planning Development of risk assessment inventory, tools and risk factor definitions Integrated risk assessment meetings with key stakeholders Development of combined OIAS Work Plan for presentation to senior management and governance 14

15 Risk Assessment and Planning Projects identified through compliance and internal audit risk assessments are summarized in internal database for further review and evaluation 15

16 Reporting Results of Risk Assessment and Work Plan Final Work Plan presented for approval includes Executive Summary, description of projects, and allocation of resources 16

17 Reporting Risk Assessment Results Final Work Plan includes graphical presentation of risk assessment results Risks graphed based on impact and likelihood Graphical presentation promotes discussion and understanding with senior management and governance 17

18 18 Reporting Results of Risk Assessment and Work Plan

19 Challenges with Integration of Compliance and Internal Audit Functions Speaking the same language Different backgrounds and professional training Interpretation or approach to a situation may be different Coordinating audits involving both areas Presenting a unified plan to OIAS customers 19

20 Challenges with Integration of Compliance and Internal Audit Functions Coordination with Audit Customers Recognizing issues to be evaluated Identifying and assigning appropriate staff based on skills and experience Recognizing each areas strengths and limitations Reporting and Follow-Up Reporting of results of compliance audits Audits conducted under attorney-client privilege Corrective action plans and follow-up 20

21 Challenges with Integration of Compliance and Internal Audit Functions Professional Audit Standards Department Charter Adherence to standards established by Institute of Internal Auditors Impact on OI staff Quality Assurance Reviews 21

22 Challenges with Integration of Compliance and Internal Audit Functions Independence Independence of Home Office OIAS from Ministry Organization operations OIAS sufficiently independent to evaluate OIP operations conducted by the Ministry Organizations Effectiveness evaluations of the Ministry Organization s OIP have been performed periodically by OIAS, with reports to senior management and governance Successful resolution of certain compliance matters with regulators led to external review and conclusion as to the effectiveness of Trinity Health s compliance program 22

23 Case Studies Physician Documentation and Coding Revenue/Charge Capture Audits Electronic Health Record Implementation Clinical Trials Hospital/Physician Contracts 23

24 Physician Documentation and Coding Typical Issues Evaluated Completeness of documentation of physician professional services Accuracy of CPT-4 coding in accordance with CMS 1995 or 1997 coding documentation guidelines Accuracy of ICD-9 diagnosis coding in specificity and sequencing Resources Assigned OI Manager Professional Services OI Specialist Professional Services 24

25 Revenue Charge Capture Audits Typical Issues Evaluated Front-end charge capture in clinical service departments Daily revenue monitoring, reconciliation, error correction processes Coding Accuracy- both hard (CDM) and soft coding (HIM) Work flow and process evaluation Resources Assigned OI Manager(s) and Specialist(s) HIM/Coding and PFS/CDM AS Manager and Senior Auditor 25

26 Electronic Health Record Implementation Typical Issues Evaluated Implementation process (e.g. readiness activities) IS system controls and data integrity (e.g. user-acceptance testing) Revenue capture, monitoring and error correction processes Chart to claim review to evaluate final billed claims for completeness, accuracy and compliance with payer requirements against documentation present Resources Assigned OI Manager(s) and Specialist(s) HIM/Coding and PFS/CDM AS Manager and Senior Auditor IS Audit Manager and IS Senior Auditor 26

27 Clinical Trials Typical Issues Evaluated Human Subjects Protection Financial controls and reporting for Federal grants Medicare billing requirements Informed Consent Resources Assigned OI Manager (PFS/CDM) & HIM AS Manager and Senior Auditor 27

28 Hospital/Physician Financial Arrangements Typical Issues evaluated Compliance with Trinity Health policies for review and approval of financial relationships with physicians including: Fair Market Value assessment Legal approval Board or delegated board committee approval Documented business purpose and/or community need All financial relationships in writing Resources Assigned AS Manager and Senior Auditor Coordination with Trinity Health General Counsel s Office 28

29 Questions and Answers Thank-You for Your Attendance and Participation! Follow-up questions can be directed to: Heidi Crosby CPA, CIA Director, Audit Services (248) James Knauf RT(R), CHC Director, Org. Integrity (248) Michael Holper CPA, CIA, CHC Vice-Pres. Org. Integrity & Audit Services (248)