3/16/2016. How to Implement a Monitoring Program Presented by: Kelly Nueske April 2016 OBJECTIVES AGENDA

Transcription

1 How to Implement a Monitoring Program Presented by: Kelly Nueske April 2016 OBJECTIVES Discuss strategies for implementing a monitoring program. For example, using the quality platform. A complete walkthrough of how to integrate monitoring into an existing compliance program. Explore different areas to monitor in each hospital department and a physician practice. How to formulate a monitoring dashboard to senior management and audit committees. Strategies of how to hold management and operations accountable for the program and monitoring. Real life challenges, how the challenges were tackled and the solutions. 2 AGENDA What, Why and Who of Monitoring Case Study Background Starting the Conversation with Management Understanding Organization Policies Understanding Department Policies Identifying existing Scorecards/Monitoring Dashboards Department Walkthroughs Implementing a Monitoring Policy Creating a Monitoring Dashboard Monitoring Examples by Department 3 1

2 WHAT IS MONITORING? Observe and check the progress or quality of (something) over a period of time; keep under systematic review. Google search, source undisclosed. Supervising activities in progress to ensure they are on course and onschedule in meeting the objectives and performance targets. 4 WHY MONITORING? The OIG believes that an effective program should incorporate thorough monitoring of its implementation and regular reporting to senior hospital or corporate officers. 50 Compliance reports created by this ongoing monitoring, including reports of suspected noncompliance, should be maintained by the compliance officer and shared with the hospital s senior management and the compliance committee. Federal Register / Vol. 63, No. 35 / Monday, February 23, 1998 / Notices Effective auditing and monitoring plans will help hospitals avoid the submission of incorrect claims to Federal health care program payors. Hospitals should develop detailed annual audit plans designed to minimize the risks associated with improper claims and billing practices. Federal Register /Vol. 70, No. 19 /Monday, January 31, 2005 /Notices 5 WHO DOES MONITORING? Monitoring Based on risk May focus on internal controls Often has a quality focus May be continuous as a part of a process Considered an internal control preventive or detective Performed by Supervisors, front line employees, Managers Auditing Independent Objective Based on risk Focuses on internal controls Systematic, disciplined approach Performed by Internal or External Auditors 6 2

3 CASE STUDY ORGANIZATION STRUCTURE HOSPITAL OUTPATIENT SURGERY CENTER SKILLED NURSING FACILITY INTENSIVE OUTPATIENT BEHAVIORAL HEALTH HEALTH SYSTEM HOME HEALTH OUTPATIENT BEHAVIORAL HEALTH (COUNTY) PRIMARCY CARE CLINICS HOSPICE 7 IMPLEMENTATION STRATEGY 1. Meet and Greet Meetings 2. Review Organizational Policies 3. Department Policies 4. Review Existing Scorecards 5. Identify correlations with existing processes 8 MEET AND GREET AGENDA Introductions Background, experience, tenure with organization Ask about them and then give them your information Department Size Find out how many employees, key services provided, volumes Department Specific Policies and Procedures Where are they located, in what format, last revised Monitoring and Auditing Activities What type of monitoring is performed by management (they will probably call them audits), is there an independent group that performs periodic audits for the department, what is management s opinion on risk areas. 9 3

4 MEET AND GREET AGENDA What reports are used by management each day to manage operations (detective monitoring). What activities occur in day to day processes to correct mistakes as the occur (preventive monitoring). What is the managers understanding of the compliance program. Opportunity to find out where the program has weaknesses Opportunity to educate manager on what Compliance s role is and where accountability for compliance rests Lastly, talk to them about your game plan for the program and solicit support 10 ORGANIZATIONAL POLICIES Review the Code of Conduct. If it is a lengthy and detailed document, does it map to administrative policies? Focus on administrative policies that also support Joint Commission Standards to identify policies that are also Compliance policies. Are the administrative policies consistent with the Code of Conduct? Who owns administrative policies? Ideally it would be business owners based on the content/policy topic. If there are inconsistencies or outdated regulatory references, now is the time to clean them up. Hold the business owners accountable for the revisions and process. Keep yourself in the support mode. 11 DEPARTMENT POLICIES Administrative or technical policies? Administrative yes review them all. What for consistency with organization administrative policies also. Technical yes some of them. Focus on those that would have a privacy, security or billing compliance component. Does the department maintain their own software with protected health information? If yes, determine if they have policies and procedures on access monitoring or other IT security related policies necessary for processes not supported by the Information Technology Department. Are there policies and procedures on charge capture or charge reconciliation? Review the OIG risk list to identify high risk services the department may need to address in policy and may need to monitor. Track suggested revisions and pull together a list of questions to address during the department walkthrough. 12 4

5 EXISTING SCORECARDS/METRICS Review past Board and Committee packets Meet with leadership staffing Board committees to find out what is shared with governance Meet with other senior leaders to find out if there are any dashboards not shared with the board but utilized by senior management It is not uncommon for performance dashboards to be driven by something else. Such as Joint Commission, Strategic Plan and a Quality Framework. Goal is to NOT replicate or duplicate anything if there is something in place that can include compliance monitoring. If it has to be created, see if you can move the organization to a dashboard that is more than compliance.key to integration into operations. 13 ALIGNMENT WITH EXISTING PROCESSES The following administrative policies were developed to meet Joint Commission Standards and were not located in a Compliance Policy and Procedure Manual. General Policies Staff Orientation Training & Education Employee Corrective Action New Employee Hire Hospital Departments & Responsibilities Hospital Committees & Responsibilities Surveys, Inspections & Investigations False Claims Statutes Incident Reports Grievance Compliant Management Privacy Policies Release of Information Business Associates Use/Disclosure of Facility Directory Accounting for Disclosures Patient Rights Confidentiality Media Relations Privacy Facsimile Transmission Amendment of Health Information Release of Chart Information 14 ALIGNMENT WITH EXISTING PROCESSES Security Policies Software Management Equipment Loan Policy Device Management Risk Assessment Asset Disposal Business Continuity Planning Disaster Recovery Data Integrity Server Back Up System Access Encryption Firewall Management Login & Password Policy Internet Access & ephi Breach Notification Remote Access Removable Media Acceptable Use Wireless Security Access 15 5

6 EXAMPLE OF JC ALIGNMENT Leadership Development Hospital Departments & Responsibilities Hospital Committees & Responsibilities Human Resource Staff Orientation Training & Education Employee Corrective Action New Employee Hire Performance Improvement Monitoring and Auditing Incident Reporting Release of Information/Patient Rights Patient Rights Confidentiality Media Relations Privacy Facsimile Transmission Amendment of Health Information Release of Chart Information 16 EXAMPLE OF JC ALIGNMENT (CONT) Information Management Release of Information Business Associates Use/Disclosure of Facility Directory Accounting for Disclosures Software Management Equipment Loan Policy Device Management Risk Assessment Asset Disposal Business Continuity Planning Disaster Recovery Data Integrity Server Back Up System Access Encryption Firewall Management Login & Password Policy Internet Access & ephi Breach Notification Remote Access Removable Media Acceptable Use Wireless Security Access 17 MANAGEMENT EDUCATION Schedule walkthroughs Why perform walkthroughs? HUGE BENEFITS! 1. Opportunity to educate management and staff. 2. Reinforces compliance training. 3. Visibility with management and staff you become human rather than a function or department. 4. You learn about operations and their challenges. 5. Find out what is going on in operations. May identify new risks during walkthrough. 18 6

7 DEPARTMENT WALKTHROUGH Schedule a min department tour with management Get a feeling of the patient flow, keep your eye open for potential risks during the tour and meet the staff. Follow up on your policy questions. Start discussion with management on monitoring activities Find out what they do today as a part of their routine management duties How is monitoring done? Who does the monitoring? How is the criteria identified and is it defined? Does a policy, regulations or both define the criteria? Ask management to review historical results with you. What is the target accuracy rate? How are high errors addressed by management? (Remediation activities) Where to monitoring results go? Share with senior management? Staff? Other? 19 PRIVACY/SECURITY WALKTHROUGHS Is performing a privacy/security walkthrough monitoring? YES Walkthrough characteristics: A specific tool is developed and includes questions to ask staff Department manager leads the walkthrough with compliance resource assisting/coaching manager (think train the trainer concept) Performed every 3 months. The first time scheduled 1 1 ½ hours depending on the size of the department. Each future time should take minutes. After the walkthrough and staff interviews are completed, review the results with the department manager and determine if there are corrective action plan needs. Discuss the corrective action plan process and how to document the process. Follow up on corrective action plans during the next walkthrough. 20 MONITORING POLICY 1. How monitoring activities are identified? based on risk 2. Who is responsible for conducting monitoring? management 3. Frequency of monitoring reporting? monthly, quarterly but no longer 4. Who is monitoring reported to? compliance department is one of the customers 5. Is monitoring a component of a corrective action plan? yes, if falls below acceptable accuracy threshold 6. What is the acceptable accuracy threshold? 90% or 95% (organization needs to decide based on their risk appetite) 7. What happens if consecutive months of monitoring results fall below accuracy threshold? define an escalation process 8. What happens if consecutive months of monitoring results meet or exceed 21 7

8 REPORTING MONITORING RESULTS Once risks are identified and monitoring needs are determined, need to develop an easy reporting tool. Suggest using Excel.because it can easily convert data to graphs (management and committees like this). Determine how many monitoring elements should be reported and how often to report information to senior management and board. May be different based on the audience. Senior Management and Compliance Committees should see results before reported to the Board or a Board Committee. 22 DASHBOARD SAMPLE & TRAITS 5 Strategic Elements 1. Customers/Service 2. People/Human Capital 3. Revenue/Growth 4. Quality 5. Expense/Cost Containment Traits of a Good Dashboard 1. Updated Monthly 2. Review by Senior Management & Presented to the Board 3. Monitored items are fluid and adjusted based on risk 4. Each item is measureable with a specific target 5. Compliance items were found in Customers/Service, Revenue/Growth or Quality. 23 WHERE TO MONITOR Emergency Department Laboratory Radiology/Imaging Surgery Pharmacy Rehab Services (PT/OT/SP) Cardio Pulmonary/Respiratory Outpatient Clinics/Departments Inpatient Units Patient Advocate Scheduling Registration Health Information Management Case Management/Utilization Review Patient Financial Services Quality Management Infection Control Information Technology Finance Marketing 8

9 Scheduling Prior Authorization (completion before appointment) Registration Errors Insurance Verification (completion prior to appointment) Registration Insurance Verification (completed during check in) Medicare Secondary Payor Questionnaire Assignment of Benefits Registration Errors Notice of Privacy Health Information Management Coding Coding Quality Management Program results Number or % of coding changes made by Coding personnel (physician charges) Productivity reports Records Management Number or % of orders unsigned (EMR reports) Average lag time for co signing verbal orders (EMR reports) Number or % of incomplete records, types of reports, etc. Quality Management Program for misfiled or comingled patient records Case Management/Utilization Review % of admissions seen within 24 hours of admission % of admissions sent to physician review for medical necessity % of physician reviews maintained as an inpatient admission Patient Financial Services Claims Submission Scrubber rejection data and trending Denials Management Tracking denial codes by payor, provider, specific segments of the revenue cycle Payment Posting Adjustments due to denials 9

10 Information Technology Access monitoring Terminated employees Finance Physician transactions/arrangements Vendor exclusion checks Marketing Marketing activities to Medicare patients Philanthropy marketing to health system patients Patient Advocate Incident reports or grievances related to billing, privacy or security. Timely response to grievances Charge Capture (any revenue generating department) Charging error reports sent to departments Charging work queues Charging errors identified or corrected by Health Information Management Charges without orders Laboratory Canceled tests Duplicate tests Radiology/Imaging Services Modified orders Pharmacy Drug diversion Charges post discharge 10

11 Emergency Department EMTALA log activities Infusion start and stop times Surgery Surgeon start and end times on back to back cases Anesthesia documentation Cardio Pulmonary Purging of ephi on mobile devices? Rehab Services Documentation of time for time based codes Accurate charge capture for time based codes Outpatient Clinic/Departments Infusion start and stop times Inpatient Units Outpatients in inpatient beds accurate charge capture QUESTIONS 33 11

12 Kelly Nueske, RN, CPA, CMA, CIA, CHC, CRMA Executive Consultant