Sampling Techniques for Auditing and Monitoring

Transcription

1 Sampling Techniques for Auditing and Monitoring HCCA 2002 Annual Compliance Institute April 23, 2002 By Darrell Contreras and Sandy Piersol

2 What does Sampling mean?! Reviewing a subset of specific components, characteristics, or items to measure against an expected result.! Sampling - Chart reviews, billing and coding reviews, etc.! Sampling the Compliance Program. 2

3 Why do Sampling for the Compliance Program?! Goal of the Compliance Program is effectiveness.! Effectiveness means?! An effective Compliance Program will: 1. Meet the criteria published by the OIG in Corporate Integrity Agreements (CIAs), AND 2. Be able to demonstrate a commitment to compliance, a culture of open communication, and a willingness to identify and correct compliance issues. 3

4 CIA Requirements! Board Reports and meetings with the CEO! Sampling: Review the minutes for documentation of reports and meetings with the CEO.! Compliance Committee! Sampling: Review the minutes for frequency and attendance.! Code of Conduct! Sampling: Review a sample of certifications! Policies and Procedures! Sampling: Review for documentation of dissemination to appropriate individuals. 4

5 CIA Requirements (cont.)! Compliance Training! Sampling: Review documentation of attendance for general and specific compliance training.! Sampling: Review documentation of timeliness of new employee training, general and specific.! Hotline! Sampling: Call the hotline to make sure it works and that reports are getting to you. 5

6 CIA Requirements (cont.)! Sampling: Review documentation and resolution of calls.! Sampling: Review publication of hotline.! Sanction Screening! Sampling: Review personnel files for documentation of OIG and GSA check. 6

7 CIA Requirements (cont.)! Other CIA requirements:! Review the Compliance Committee charter for CIA components;! Review the Compliance Officer job description to ensure components are included;! Review the Code of Conduct to see if the language matches or is close to a match;! Review the Training policy to see if it meets the CIA requirements;! Review the Hotline policy to see if it meets the CIA requirements;! Review the Sanction Screening policy to see if it meets the CIA requirements. 7

8 Sampling Effectiveness by Evaluating the Compliance Culture! Compliance Officer! Do employees know who the CO is and how to contact him/her?! Code of Conduct and Policies and Procedures! Do employees know about the Code of Conduct?! Does it provide guidance?! Is the location of P&P s known and are they used for guidance?! Were the training programs effective?! Are issues discussed in training occurring repeatedly?! Does post-testing indicate an understanding of Compliance? 8

9 Sampling Effectiveness by Evaluating the Compliance Culture (cont.)! Hotline! Do employees know about the Hotline?! Are they willing to use the Hotline?! Non-Retaliation Policy! Do employees know about and believe the Non- Retaliation Policy?! Repayments! Is documentation of overpayments available?! Is there a policy for making repayments or voluntary disclosure? 9

10 Sampling Effectiveness by Evaluating the Compliance Culture (cont.)! Auditing and Monitoring! Has an annual audit workplan been developed?! Does it include OIG workplan issues, fraud alert issues, and issues from other resources?! Was the Compliance Committee involved in the identification and prioritization process?! Is the priority list realistic?are issues discussed in training occurring repeatedly?! Does post-testing indicate an understanding of Compliance? 10

11 Sampling Techniques for Measuring Effectiveness! Compliance Office reviews of documentation.! Surveys of employees to measure the Compliance Culture that include specific Compliance Program components.! Organization-wide risk assessments based on compliance themes. 11

12 Questions 12

13 Sampling Methodologies Things to Consider:! The purpose of the sample or the review objective! The universe/population/sources of data! The size of the sample! What you are going to do with the results????????????????? 13

14 Purpose of the Sample! Is the review for :! Self - disclosure?! Education?! Part of an on-going monitoring plan?! Response to the federal government, subpoena, carrier or FI?! Known risk area? 14

15 Sample Size! How much is enough?! Do you need to test every provider/physician/department? 15

16 Examples:! A minimum of 10 claims for reimbursement per provider will be reviewed representing a cross-section of out-patient and inpatient E&M services. This works for monitoring but if trying to do a statistical sample the sample size will need to be larger to meet precision and confidence. 16

17 Examples:! Review 5 inpatient and 5 outpatient This is very specific and may not be as efficient and the sample could get very large if trying to use a statistically valid sample. 17

18 Statistical vs. Non-statistical Samples! There are many ways to make samples statistically valid.! Probe/Discovery Samples are used mainly to determine the size of the full sample in order to meet the required precision and confidence levels. 18

19 Statistical vs. Non-statistical Samples ( cont.)! Precision and Confidence What does this mean???! Extrapolation How does it hurt and how does it help?? 19

20 Statistical Samples You need to define:! Population: (what is included and what is not)! Sample Frame Description: A description of the sampling frame, which is the totality of Items from which a probe and full sample have been selected.! Sample Unit: what you are going to use to draw the sample 20

21 Statistical Samples ( cont.)! List of estimates to be obtained from the review! Sample specifications/ confidence/ precision Sometimes is does not make sense to review a statistical sample 21

22 Non- Statistical samples! Population! Sample frame! Sample unit 22

23 Reasons for Sampling! Baseline assessments! Annual Auditing! CIA requirements ( Billing Engagement/Claims Review) 23

24 Baseline Assessments! Here is where you may want to test/monitor every provider/department etc.! The baseline assessment should be tied into your compliance plan.! Determine if the baseline assessment will be pre-bill claims or after the claim has been submitted. 24

25 Annual Monitoring! Many compliance programs require the testing of all providers every year.! The compliance program should state what happens when there are errors during the annual monitoring program. 25

26 CIA Requirements For the Billing Engagements in CIAs there have been new guidelines:! The Claims review shall include a Discovery sample of 50! If the error rate( as defined..) for the Discovery sample is less than 5%, no additional sampling is required! If the Discovery sample indicates that the Error rate is 5% or greater shall perform a Full sample.. 26

27 Summary! There are many ways and reasons to sample or test.! Remember to :! Determine why you are testing! Who or what you want to test! What you are going to do with the results 27

28 Questions and Answers Sandy Piersol Senior Manager Deloitte & Touche LLP National Healthcare Regulatory Services Practice (215) Darrell Contreras Manager Ernst & Young LLP Health Care Advisory Services Practice (602)