Conducting your own audit: What to do, how to do it
If you're serious about setting up an effective system of compliance, it's crucial first to get a handle on what trouble spots already exist in your facility. That means biting the bullet and commissioning an audit of how your organization does business, says G. Michael Barton, SPHR, vice president of human resources at Regional Medical Center in Madisonville, KY.
That's especially true for multi-hospital chains or health systems. "From chain to chain, you would think your billing processes and your medical record coding processes, for example, would be pretty standard," Barton says. "But you need to make sure that they are, and that means doing an audit."
Audits should be specific to each hospital and use a standard set of assessment tools to evaluate possible risk areas. But don't limit the audit only to obvious departments, Barton cautions. "Mostly what you hear about is Medicare and Medicaid fraud," he says. "That means billing, financial issues, and some human resource issues. But it's going to become a lot more broad-based as you see the whole area of
safety - safety in staffing, and in safe medical practices."
Some hospitals and systems, however, haven't pursued doing a thorough, objective audit because of the likely expense. Many, particularly small hospitals, take the attitude that, because they're small fish, they have less to fear from federal investigators, Barton says. "But it really can happen to anyone - fines of $4 million or $5 million. It's been hard for some hospitals to absorb that fact," he says.
Barton acknowledges that an audit of the scope he recommends could get expensive, but he notes that it can easily pay for itself if and when federal investigators come knocking. "When they come in, the bargaining zone can be anywhere from 5% to 95%," he says. "Or there could be no bargaining zone at all. You know there's going to be some kind of fine, because they can almost always find something. But if you have a good compliance program in place and can show that you've done an outside audit in good faith, you can bargain almost 90% to 95% of that away."
Outside audits are preferable, Barton says, because investigators view them as more objective. "With an internal audit, you're not going to be looking at things with fresh eyes," he adds.
Still, even if your facility isn't willing to lay out the funds for a comprehensive external audit, there are things you can do to improve the validity and reliability of any internal audit you conduct. It's best if you already have an internal auditing function at the facility. Barring that, Barton recommends placing responsibility for the audit in the hands of risk management, or a carefully selected audit team.
"You have to have individuals who are very detail-oriented," Barton says. "Accountants, clinical individuals. Masters-prepared nurses can certainly look at things and say 'You know, we have too many procedures ordered in this particular case. And this could get us in trouble if someone were looking at that.'"
Whoever you select for an audit team, it's vital that the facility make it clear there will be no negative ramifications for the team members if they do find errors.
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