ealth care agency edical illing process for the ......lts tive #1: o ate to ensu mendations tive #2:...
TRANSCRIPT
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American Institute of Certified Public Accountants Award to Dr. Peter Hughes as 2010 Outstanding CPA of the Year for Local Government
GRC (Government, Risk & Compliance) Group 2010 Award to IAD as MVP in Risk Management
2009 Association of Certified Fraud Examiners’ Hubbard Award to Dr. Peter Hughes for the Most Outstanding Article of the Year – Ethics Pays
2008 Association of Local Government Auditors’ Bronze Website Award
2005 Institute of Internal Auditors’ Award for Recognition of
Commitment to Professional Excellence, Quality, and Outreach
RISK BASED AUDITING GAO & IIA Peer Review Compliant – 2001, 2004, 2007, 2010
Inte
rnal
Aud
it D
epar
tmen
t INTERNAL CONTROL AUDIT:
HEALTH CARE AGENCY MEDICAL BILLING PROCESS
For the Period March 1, 2010 through June 30, 2011
AUDIT NO: 1018
REPORT DATE: DECEMBER 13, 2012
Director: Dr. Peter Hughes, MBA, CPA, CIA Deputy Director: Eli Littner, CPA, CIA
Senior Audit Manager: Michael Goodwin, CPA, CIA Senior IT Audit Manager: Autumn McKinney, CPA, CIA, CISA
Audit Manager: Winnie Keung, CPA, CIA IT Audit Manager: Wilson Crider, CPA, CISA
Our audit found that internal controls over the Medical Billing Process are adequate to ensure the billings are allowable, valid, and adequately supported. Key controls such as pre-billing and post-payment reviews are in place to help detect incomplete or improper billings. Our audit also found IT application controls over the medical billing process are adequate in the areas of: (1) user access (password and account management), (2) segregation of duties, (3) system edit checks, (4) system enforced holds/queues, and (5) transactional audit trails. Additionally, IT general controls as related to the medical billing systems (IRIS and Practice Expert) are adequate in the areas of: (1) change management, and (2) backup and recovery. The medical billing process is complex and involves an extensive coordination of efforts between clinics, medical billing, quality assurance, and system personnel. We commend HCA on their established controls and process. During FY 10/11, HCA’s annual medical billings totaled $73 million for services provided under HCA’s Behavioral Health, Public Health, and Medical and Institutional Health Services Programs. We identified four (4) Control Findings where HCA should continue efforts to complete business continuity planning documents; consider reducing the extent of its pre-billing and post-payment reviews; and evaluate generating management reports from the IRIS system for monitoring the effectiveness of the medical billing process.
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witz, Directore Agency
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Tab InterMedAudi For t Trans OC In O R B S S Deta Findi(Cont FindiServ Findi(Cont Findi ATTA ATTA ATTA
ble of C
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it No. 1018
he Period M
smittal Lett
nternal AudOBJECTIVESRESULTS BACKGROUSCOPE ANDSCOPE EXC
iled Results
ing No. 1 – trol Finding
ing No. 2 – ices Claims
ing No. 3 – trol Finding
ing No. 4 –
ACHMENT A
ACHMENT B
ACHMENT C
Conten
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ter
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June 30, 20
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InMA
Audit
We audiadequacand systover HCBilling P During FHCA’s mtotaled million fHealth, Pand MedInstitutioServicesthrough operatedcontract
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nternal Control AuMedical Billing ProAudit No. 1018
OC Int
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of manual anlings are allo
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A’s business
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ling Process
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HCA’s medicalid.
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Page 1
2
ed by the al Control audit was Standards re to:
cal billing
lp detect
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ce Expert
(e.g., no ssment to ost-billing
ocess are dings and
equate in
ses in the password
e.g., data
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InMA
OCBs TtA
nternal Control Au
Medical Billing ProAudit No. 1018
OC Int
Objective #5Control FindBehavioral Hsystem to gen
The followinghe Detailed
Attachment A
Finding No. Cl
At1.
2.
3.
4.
udit: Health Care Aocess
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5: Our audidings where ealth Servicenerate mana
g table summd Findings, RA for a descri
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(see ttachment A) Control Finding
Control Finding
Control Finding
Control Finding
Agency
Auditor
it found therHCA can co
es and Publiagement repo
marizes our fRecommendption of Rep
FindPage No. i
Need to CoBusiness CPlanning DoHCA has cosubmitted aBusiness Cdocuments to CEO/IT. Pre-Billing aPayment ReBehavioral Services Clis an opportevaluate thebilling and previews perMedicare aclaims due rates. (Pgs Post-PaymePublic HealClaims -Theopportunity frequency asizes used performed oPact Progra Utilization oManagemeIRIS containdata and rebe used forpurposes. certain inforreports are available. (
r’s Rep
re were no bonsider reduic Health Seorts.
findings and dations and ort Item Clas
ding and n Audit Repor
omplete Continuity ocuments - ompleted andabout 9% of tContinuity Pla
(Phase 1 of (Pgs. 14-15)
and Post-eviews for Health laims - Theretunity to e extent of ppost-paymenrformed on nd Medi-Cal to low error
s. 16-18)
ent Reviews lth Services ere is an to evaluate t
and sample in the reviewon the Familyam. (Pg. 18)
of IRIS nt Reports -ns valuable
eports that car analytical However, rmation or not readily
(Pg.19)
ort
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recommendManagemen
ssifications.
rt R
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an
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duplication oent of pre-pacal billings, a
ations for thnt Response
Recommendat
hould make etion of the Css Continuityents a priorit
te pre-billingnt review proedicare and with consideing the frequs and sample
te post paymprocess ovefor Family Pm with consiifying the fre
ews and sam
te the ability ate IRIS manas to help monte the process for behaviomedical serv
ed and billed
of work. Wayment and pand can cons
is audit. Seees section o
tion M
County’s y Plan ty.
and post ocess Medi-Cal
eration of ency of e sizes.
ment er PHS act deration quency
mple
to agement
nitor and sses and oral vices .
e identified post-billing resider utilizing
e further discof this repo
Concurrence by
Management?
Yes
Yes
Yes
Yes
Page 2
three (3) eviews of
g the IRIS
cussion in ort. See
?
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InMA
B( Hapf 1
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3
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MTfCMt
BHptsbtpnternal Control Au
Medical Billing ProAudit No. 1018
OC Int
BACKGROU(See Detailed
HCA’s Missioand our diverplanning & pfollowing four
1. Behaviordrug abusfor the yeservices month’s bincluding BHS claim
2. Public Hdevelops HCA’s bidifferencethrough M
3. Medical services tFY 10-11differencebilled thro
4. FinanciaAccountis the Meprovided
Medical BilliThe MBU profor reimburseCounty-operaMBU does nhe service ar
County-OClinics
ContractContract
BHS ContracHCA contracproviders arehe County’s
same electrobut does not o their cont
provide BHS udit: Health Care Aocess
ternal A
UND SUMMAd Backgrou
on Statemenrse communipolicy develor service area
ral Health Sese treatmentear. This amreceived. If billings. DurState Realig
ms are billed
Health Servipreventive
illings totalees exist betwMedi-Cal.
and Institutto persons fo1, HCA’s bes exist betwough Cal-Opt
l and Adming Servicesedical Billinin County-op
ng Unit ovides speciement for serated clinics, not prepare reas provide
Operated
t Entities/ t Providers
ct Providerscts with vende responsibleIRIS systemnic file as thepass throughract agreemservices on
Agency
Auditor
ARY nd of Medic
nt: Dedicatedities through opment, prevas:
ervices (BHt to eligible remount include
self-pay invring FY 10-1gnment Fund through Med
ces (PHS) strategies to
ed $1,849,11ween amount
tional Healtor whom the illings totalween amountima. We did
ministrative s, an Auditorng Unit (MBperated clinic
alized medicrvices providHCA also usor process d through HC
For Mentaand for CoAlcohol & DServices For Mentaand AlcohoServices
s dors (contrace for entering
m. The contrae County’s clh payments t
ment. There behalf of HC
r’s Rep
cal Billing Pr
d to protectinpartnerships
vention & ed
S) provides cesidents. Dues “self-pay” oices are no
11, HCA recds, are receivdi-Cal.
monitors theo maintain a14 for the yets billed and
th ServicesCounty, by lled $111,81nts billed andd not include
Services pr-Controller SBU), which pcs.
cal billing sered to its clienses contractany claims CA/County-o
BHSl Health Servic
ourt-ordered Drug Abuse
l Health Servicol & Drug Abus
ct providers)g their medicact providerslaims. The Cto them. Inst
are 33 CoCA. We did n
ort
rocess in At
ng and promos, communityducation, an
countywide muring FY 10-billings to cli
ot paid in fulleived paymved in arrear
e incidence and improve ear and recepayments re
(MIHS) provaw, has resp6 and reced payments MIHS in our
provides inteSatellite Accoprovides spe
rvices and snts in Countytors to providfor contractperated clini
ces County eservices and OranHome
ces se
None
) to provide cal billings ans’ claims are County receivtead, HCA paunty-operat
not include co
ttachment C
oting the optiy leadership, d quality se
mental health-11, HCA’s Bients who hal, the invoice
ments totalinrs, so timing
of disease athe health o
eived paymeeceived. The
vides emergponsibility foreived paym
received. Tr scope due t
ernal suppoounting Unit.ecialized med
upports HCAy-operated cde BHS servtor-operatedcs and contr
MIHSemployees provat Juvenile Ha
ngewood Child
behavioral nd claims (gethen submittves paymentays the contrted clinics aontract provid
)
imal health oassessmentrvices. HCA
h care servicBHS billingsave a financiaes are includng $41,458,1
differences e
and injury inof the publicents totaling
e majority of P
ency care ar providing suents totalinThe majorityto the low vo
ort to HCA, Within HCAdical billing
A by preparinclinics. For Bvices. It is id clinics. Thract providers
vide all dren’s
For PuServic
None
health servicenerally for Mted to the Stat for the contrract providersand 86 conders in the sc
of individuals,t of communi
A is comprise
es and/or alcs totaled $71al obligation ted in the su34. These pexist. The m
n the commuc. During Fg $1,852,665PHS claims
and essentiauch servicesng $59,719. y of MIHS cllume of billin
and includA Accounting services for
ng billings anBHS, in additmportant to he table belos:
PHS ublic Health es
ces. TheseMedi-Cal) dirate for paymract providers in arrears a
ntract providcope of this a
Page 3
, families, ity needs, ed of the
cohol and 1,026,950 to pay for bsequent
payments, majority of
unity and FY 10-11, 5. Timing are billed
l medical . During Timing
laims are ngs.
des HCA Services services
nd claims ion to the note that
ow shows
e contract rectly into ent in the
rs’ claims, according ders that audit.
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InMA
Asrc MH
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nternal Control AuMedical Billing ProAudit No. 1018
OC Int
As such, HCservices are regulations; acompliance is
Correctin Deducting Refundin Paying an Submittin
Medical BilliHCA utilizes
1. IRIS Systto Medicaincludes: performaaiding theProFit is
2. Practice demograp
3. EDIfecs files priorperform it
Overview of The medical services provbilling procesDetailed Bacprocesses for
1. FinanciaRegistratperforms (Medicareclient’s fiproducedfinancial i Encounteknown asservices/t Data Entrdata valid
2. Pre-BillinOnsite prprior to su
udit: Health Care Aocess
ternal A
CA has onlyprovided; ve
and providingssues by the
g and resubmg void claimsg any amounny recoupmeng Medicare o
ng Informatthree key sys
tem: For BHare, Medi-Caclient regist
nce and mane production the billing m
Expert Sysphic informat
Software: Hr to submittints HIPAA dat
Medical Bilbilling proc
vided and susses and sysckground in r BHS and P
l Evaluationion/Intake: Pa financial
e, Medi-Cal, nancial resp
d from the syinformation is
ers: Each tims an encounttreatments a
ry: Encountedations as the
ng Reviews re-billing reviubmission as
Agency
Auditor
y administraterifying propg training. Ncontract pro
mitting any ds from future nts identified ent and/or peor third party
tion Systemsstems/softwa
HS, HCA useal and other ttration and snagement of and exchangodule of IRIS
stem: For Ption, reportin
HCA utilizes g billings andta validations
ling Processcess starts wubmitting elestems for BeAttachmentHS:
n and Clinic Prior to provevaluation tCalOptima, e
ponsibility. Aystem for thes entered int
me a patienter. A Progrnd to suppor
ers are entere information
iews are pers follows:
r’s Rep
tive responsper documenNeither the Coviders. The
denied claimsclaims (systduring a pos
enalties resulty claims direc
s are to suppor
es the Integrathird parties, scheduling, m
billing activige of health S.
HS and MIHg, and proce
EDIfecs softd claims to ths.
s with the regiectronic billinhavioral Heat C. Below
Visits iding clinic sto determineetc.) and comAn UMDAP e client to sigo the applica
t visits a clinress Note anrt the medica
ed into the an is being ent
rformed to en
ort
sibility over tation is maounty nor HCcontract prov
s that are ideem automatist payment/bting from a S
ctly (not part
rt the medica
ated Recordsand reportin
management ties in compcare informa
HS, HCA useessing billings
tware to perfhe State and
istration/intakng documentalth and Pub
is an overv
services, the e eligibility fompletes the e(Uniform Me
gn up for BHable system (
nic where a nd Encounteal billing.
pplicable systered for BHS
nsure claims
the contractintained; ensCA have anyviders are re
ntified by HCcally withholdilling audit
State claim auof County pr
al billings:
s Informationng to the Sta
and reportinliance with Sation with ext
es the Practis.
form HIPAA d to Medicare
ke of clientsts to the Stalic Health Seview of step
patient meeor various mevaluation in ethod for DeS services. (IRIS or Prac
clinician pror Document
stem based oS only.
s are accurat
tor operatedsuring compy financial obesponsible fo
CA ds)
udit rocesses or b
n System (IRIte of Californng of medica
State and Fedternal parties
ce Expert sy
data validatie. The State
s through doate. There aervices as nops involved i
ets with a Finmedical reimthe system,
etermining AThe patient
ctice Expert).
ovides servic(ED) are co
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te, complete
d clinics for pliance with rbligations for r:
billings)
IS) to facilitatnia. IRIS funal tests, repoderal regulats in a secure
ystem for reg
ons on the ee also uses E
ocumenting are differencoted below ain the medic
nancial Evalumbursement p
which determAbility to Pay
is registered
ces/treatmentompleted to d
The systems
e, and valid/s
Page 4
ensuring rules and any non-
te billings nctionality orting the tions, and e manner.
gistration,
electronic EDIfecs to
the clinic ces in the and in the cal billing
uator who programs mines the y) form is d and the
ts, this is document
s perform
supported
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InMA
3
4
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nternal Control Au
Medical Billing ProAudit No. 1018
OC Int
All BHaccurstatusHolds
PHS
Revieare p“Hold
3. SubmissClaims foedits to vare batchfile is whMedi-Calfile/claim created fo Acce
Medic
Rejecreturn
4. AdjudicaOnce BHreview) is Appr
Denie
Medi-rebillihealth
Adjudicat
5. PaymentHCA rece
6. Post-BillOnsite poif the claim BHS:
ChildAdult
PHS:perfoTreat
udit: Health Care Aocess
ternal A
HS Medicareracy prior to sses, which ins). Upon pas
claims, excews at #6 berocessed in s.” The pre-
sion of Billinor BHS servicvalidate the ched into an eat is sent to ’s local editswill either b
or third party
epted Claimscare.
cted Claimsns the entire
ation of ClaimS claims are
s downloaded
roved Claims
ed Claims. -Cal claim wng. The dehcare plans a
ted claims fo
t to HCA eives paymen
ing Reviewsost-billing revm needs to b
All BHS Mren and YouMental Heal
In generalrmed. MBUtment (FPAC
Agency
Auditor
e and Medi-Csubmission. ndicates a sssing the pre
cluding Familow) are selePractice Exp
-billing review
ngs to Claimces are geneclaim. Claimelectronic 837
the State ors by the EDIbe accepted
y healthcare p
s. File passe
s. A rejected837 file/claim
ms – Approve adjudicatedd into the IRI
s. Approved
A denied stawill be automenied claim care processe
r PHS and M
nt for all claim
s views are perbe credited o
Medicare paiuth Services lth Service pa
, PHS claimU does condCT) Program o
r’s Rep
Cal claims go These claim
specific reviee-billing revie
ly Planning ected to go thpert. Practicw occurs prio
ms Processoerated by the
ms are gener7 file on a wer to MedicareIfecs softwar or rejectedplans and ma
es the edit ch
d status is nom to HCA, wh
val or Deniad, an 835 batS/ProFit mod
d claim paym
atus is a finalatically placecan be appeed manually.
MIHS are dow
ms submitted
rformed to idr refunded.
id claims hago through
aid claims do
ms have preuct post-payon a sample
ort
o through a pms are electro
w is neededew, the electr
Access Carhrough pre-be Expert doe
or to entering
r e applicable srated as eleceekly basis fe by HCA, are prior to bed by the EDailed to the in
hecks and wi
ot a final adjhere it will be
al tch file (the 8dule and incl
ents are pos
l adjudicationed in the Teealed by sub
wnloaded and
d, including c
dentify inaccu
ave a post-ba post-billin
o not go thro
e-billing revieyment reviewbasis as it d
pre-billing revonically routed (e.g., Coderonic hold is r
re and Treabilling reviewses not have athe billing in
system afterctronic claimsfor BHS or oand is validateing transmitIfecs softwansurance car
ll be adjudica
judication fore researched
835 file is creludes the foll
sted into the c
n for a specifchnical Deni
bmitting a co
d recorded in
contractor-op
urate or inco
illing review.g review on ugh a post-b
ews; therefows on the Fadoes not go th
view to ensued in IRIS. IRer Holds, Qreleased by t
atment Progrs on a sampany system e
nformation int
r going througs. Medicare n a daily basted against Htted to the c
are. Paper Crrier.
ated (accept
r a claim. T for correctio
eated after thowing:
correspondin
fic claim. Thial work queorrected claim
nto Practice E
perated clinic
mplete paid
. Paid BHSa sample b
billing review.
ore, post bilamily Plannihrough a pre
ure completeRIS has vario
QIPC Holds athe reviewer.
ram (see Pople basis. PHenforced or eto Practice E
gh a series oand Medi-C
sis for PHS.HIPAA standclaim processCMS-1500 cl
ed) by the St
he State or on and resub
e State or M
ng IRIS accou
he denied Meue for correcm. Denials
Expert.
s.
claims and d
S Medi-Cal cbasis. BHS
ling reviewsng Access C
e-billing review
Page 5
ness and ous ‘Hold’ and MRT .
ost-Billing HS claims electronic
Expert.
of system Cal claims
The 837 dards and sor. The aims are
tate or by
Medicare mission.
Medicare’s
unt.
edicare or ction and for other
determine
claims for Medi-Cal
s are not Care and w.
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InMA
SOta 1
2
3
4
5
SO
MISpaswcCc IBocAbdA
nternal Control AuMedical Billing ProAudit No. 1018
OC Int
SCOPE ANDOur audit evahe period M
and testing of
1. Evaluatiooperated
2. Evaluatioclaims anMedi-Cal
3. Evaluatiofor BHS M
4. Evaluatioaccount holds/que
5. Evaluatioareas of c
SCOPE EXCOur audit did
Billing an Billing an Billings a IT genera
were movaudit of H
IT applicascope. W
Complian Complian Patient’s Controls Controls
Managemenn accordanc
Systems: “Alpart of their mand maintainstrengtheningweaknesses,control structControl Audicontinuing em
nherent LimBecause of ioccur and nconstraints, uAlso, projectibecome inaddeteriorate. Accounting’s
udit: Health Care Aocess
ternal A
D METHODOaluated internarch 1, 2010f relevant do
on of manualclinics to en
on of controlsnd PHS Medclaims to en
on of controlsMedi-Cal andon of IT App
managemeneues, and traon of IT Genechange mana
CLUSIONS not include a
d claims for d claims subnd claims foral controls inved from HC
HCA as a whoation control
We did not pence with HIPAnce with billineligibility for over cash reover cost rei
t’s Responsce with thel County dep
managementning the interg internal co when detecture is the Cit enhances mphasis on c
mitations in Anherent limitot be detecunintentionalon of any evequate becaAccordinglyoperating pr
Agency
Auditor
OLOGY nal controls a0 through Jucuments ove
and systemsure medica
s over pre-bildi-Cal claims,nsure medicas over post-bd PHS Medi-Cplication Connt), segregatansactional aeral Controls agement and
a review of th
Medical and bmitted to thirr services pro
n the areas oCA to the OCole. s reviewed
erform a comAA or other png rules and rmedical benceipts and ambursement
sibilities for Auditor-Copartments/agt practices. Trnal control sontrols.” Cocted, must b
Committee ofand compl
control activit
Any Systemtations in anycted. Specifl errors, mavaluation of tause of chang, our audit wrocedures, ac
r’s Rep
and processeune 30, 2011er the followin
m controls anl claims are aling reviews, and b) Qua
al claims are billing/paymeCal claims. ntrols (IRIS tion of dutieudit trails. related to th
d backup and
he following:
Institutional rd-party healovided by coof IT adminisC Data Cente
were limitedmprehensive aprivacy laws. regulations e
nefits. ccounts recet for medical
Internal Conntroller’s Co
gencies shallThis is becausystem. All lontrol systembe promptly f Sponsoringements, buties and self-a
m of Internal y system of fic examplesnagement othe system toges in conditwould not neccounting pra
ort
es over sele. Our methng:
nd processesallowable, vaat: a) HCA’s
ality Improveallowable, vant process a
and Practices, system
he medical bid recovery.
Health Servith plans, inclntract provid
stration/strateer); and secu
to those mapplication re
established b
eivable/collecservices fun
ntrols ounty Accou maintain effse managemlevels of ma
ms shall be corrected. T
g Organizatiot does not assessment
Control internal cont
s of limitatioverride, circo future periotions or the decessarily diactices, and
cted aspectsodology inclu
s over medicalid, and adeqs Medical Billment & Progalid, and adeat QIPC for B
ce Expert) oedit checks
lling systems
ices (MIHS). luding Denti-
ders (non-paregic planningurity administ
edical billingeview of IRIS
by Medicare a
ctions pertainded by grant
unting Manufective intern
ment has primnagement mcontinuouslyThe criteria ons (COSO) substitute foof control ris
trols, errors ons include, umvention bods is subjec
degree of comsclose all wcompliance w
s of the mediuded inquiry
cal billings inquately suppling Unit (MBgram Compliequately suppBHS Medi-Ca
over user ac(e.g., data
s (IRIS and P
-Cal and Cal-r). g; physical setration. We
g objectives S or Practice
and Medi-Ca
ning to medicts and State
ual Section nal control symary respons
must be involvy evaluated for evaluatincontrol fram
or, HCA ansks.
or irregularitbut are not
by collusion, ct to the risk mpliance witheaknesses iwith County
ical billing pry, auditor obs
itiated at theported. BU) for BHS ance (QIPC)ported. al claims and
ccess (passwvalidations)
Practice Expe
-Optima.
ecurity (sincedid not perfo
covered by Expert as a w
al.
cal billings. allocations.
S-2 Internaystems as ansibility for estved in assesby Managem
ng an entity’smework. Oud HCA Acc
ies may nevt limited to,
and poor jthat proced
h the procedn the HCA’spolicy.
Page 6
rocess for servation,
e County-
Medicare ) for BHS
d at MBU
word and ), system
ert) in the
e servers orm an IT
the audit whole.
l Control n integral tablishing ssing and ment and s internal r Internal
counting’s
vertheless resource
udgment. ures may ures may
s or HCA
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InMA
AWpM A D
nternal Control AuMedical Billing ProAudit No. 1018
OC Int
AcknowledgWe appreciapersonnel duMichael Good
Attachments
Distribution P
MembersMembersRobert J.Steven EJeff NageJan GrimKimberly Leslie SoTeri SchuAdil SiddiJohn MooDoug PhaThea BulDavid HoForepersSusan No
udit: Health Care Aocess
ternal A
gment ate the courturing our auddwin, Senior
s
Pursuant to A
s, Board of Ss, Audit Overs Franz, Interldred, Interim
el, Ph.D., Depes, Chief DeEngelby, Ma
orrells, Managultz, Chief Infiqui, IRIS Dirore, IRIS Opean, Managerlock, Chief C
orner, Divisionon, Grand Juovak, Clerk o
Agency
Auditor
esy extendedit. If we caAudit Manag
Audit Oversig
upervisors sight Commiim County Ex
m Deputy CEputy Agency
eputy Auditoranager, HCAger, Medical formation Offrector, HCA/Ierations Manr, HCA/InformCompliance an Manager, Qury of the Board o
r’s Rep
ed to us by n be of furthger at 834-60
ht Committe
ittee xecutive Offi
EO, GovernmDirector, Fin-Controller
A Accounting Billing Unit,
ficer, HCA nformation T
nager, HCA/Imation Technand Privacy OQuality Impro
of Superviso
ort
the Health Cher assistanc066.
e Procedure
cer ment and Pubnance/Admin
Services HCA
Technology nformation T
nology Officer, HCAovement and
rs
Care Agencyce, please co
No. 1:
lic Servicesnistrative Serv
Technology
d Program Co
y and HCA ontact me di
vices, HCA
ompliance, H
Accounting irectly at 834
HCA
Page 7
Services’ 4-5475 or
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l Control Audit: Hel Billing Process
No. 1018
ed Resugement
ctive #1: Evess to ensure
k Performederformed the
Obtained andPolicies and P
Obtained a deServices and re-billing rev
Obtained repoYears 2009-10
Conducted mesponsibilitie
Program Com
Conducted moncerning the
Performed sitend Children
nterviews, peegistration, eeviews of Me
Observed theExpert at the c
Reviewed doche medical bi
Obtained an ocuments sh
Obtained an u
clusion d on our audnd Medicarellowable, sup
An extensive ost paymentccurate prior
he quality asMedi-Cal, etc.nsure contin
ealth Care Agency
ults, FinRespo
valuate the ae the billings
e following to
d reviewed HProcedures p
etailed underPublic Healtiews, submis
orts of total m0 and 2010-1
meetings withs over med
mpliance, and
meetings witheir roles in th
e visits at fou& Youth Sererformed wa
encounter anedi-Cal and M
e processingclinics and in
cuments andilling process
understandihowing the de
understandin
dit, we founde claims are apported, and
quality assut audits perfor to submissio
ssurance pro.) that is deteued eligibility
y
ndingsonses
adequacy ofare allowable
o accomplish
HCA Behaviopertaining to t
rstanding of th Services, ssion of claim
monthly billing11 for each o
h HCA mandical billing, d Claims and
h HCA Divisihe medical bi
ur HCA clinicrvices at the alkthroughs,
nd billing infoMedicare BHS
g of billings n the Medical
d reports gens, including th
ng of the menial and rep
g of the re-b
d manual andadequate andvalid. Key c
urance proceormed for BHon for payme
ocess includeermined duriny for reimburs
, Recom
manual ande, supported
our audit obj
oral Health Sthe medical b
medical billinstarting with
ms to the Stat
gs and claimof the above
agement to including MFinancial Re
on Program illing process
cs (17th StreeManchesterand obser
ormation, obS & PHS clai
and claims l Billing Unit.
erated from he various w
medical billinpayment of cl
illing process
d system cond effective to
controls that w
ss is in placHS & PHS cent.
es re-verifyinng initial intaksement prior
mmend
d system co, and valid.
jective:
Services andbilling proces
ng process a patient regite, and post-
ms submitted,divisions.
obtain an uMedical Billineporting.
Managers as.
et Clinic, Sanr Office Buildrved the proserved pre-bims.
in IRIS (Pro
IRIS to undeork queues a
g submissiolaims.
s when claim
ntrols over mo ensure billinwe identified
ce that is achlaims to ens
g the client’ske and registr to submitting
dations
ntrols over H
d Medical Biss.
and controls stration, pati
-payment rev
and paymen
understandinng Unit, Qu
and HCA/Inf
nta Ana Cliniding). At theocessing anbilling and/or
oFit billing m
erstand how and system h
on process a
ms are rejecte
medical billingngs and claim under this o
hieved througsure they are
s program eltration for BHg claims for p
and
HCA’s medic
lling Unit’s O
for Behaviorient visits/enviews.
nts received
ng of their rality Improv
formation Te
c, Costa Mee clinic, we cnd inputting r post-billing
module) and
the system iholds.
and reviewe
ed or denied.
g processes ms for reimbobjective inclu
gh the pre-be valid, comp
igibility (for MHS only. Thispayment.
Page 8
cal billing
Operating
ral Health counters,
for Fiscal
roles and vement &
echnology
sa Clinic, conducted
patient’s payment
Practice
s used in
d related
for Medi-ursement ude:
billing and plete, and
Medicare, s helps to
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Our coordProgrHCA billing As su
l Control Audit: Hel Billing Process
No. 1018
ed Resugement
he quality auch as patien
naccurate or dentified and
here are woillings are suor quality aspproved.
When errors, ocumentatiohe billing. Rillings.
HCA has adolaim is impeimbursemenny billings or
audit found dination of eram Compliaon the contr
gs are allowa
uch, we hav
ealth Care Agency
ults, FinRespo
assurance prnt charts, clinincomplete resolved bef
rk queues aubmitted. Thssurance. E
inaccurate cn is returned
Re-billings go
pted a conseroper, incomnt. HCA will r claims when
that HCA’seffort betweeance (QIPC)rols and procable, supporte
ve no finding
y
ndingsonses
rocess ensurnic notes, anclaims that dfore being su
nd system hhese reviewsExplanations
laims or unsd to the clinio through the
ervative apprmplete or inattempt to c
n there is a p
s medical ben HCA clin, Administracesses they ed, and valid
gs and recom
, Recom
res that claind other docudo not have ubmitted for p
holds in places include med
are docume
upported clac/health caree same wor
roach in mednaccurate, itorrect the bil
possibility tha
billing procenics, the Metion, and Infestablished o
d.
mmendation
mmend
ms are adequmentation othe necessa
payment.
e that requiredical team cented when
ims are detee provider fok queues, h
dical billing, at does not lling issue in at the claim c
ess is compedical Billingformation Syover the med
ns under this
dations
quately suppof medical seary supportin
e reviews to hart reviewsclaims are
ected in the por correction olds, and re
and if there isget submittorder to re-b
could be rejec
plex and in Unit, Qualiystem persodical billing p
s objective.
and
ported by doervices providng document
be conducte, coding reviput on hold
pre-billing revand resubm
eviews as the
s any indicatted to the Sbill, but will ncted or denie
volves an eity Improvem
onnel. We cprocess to en
Page 9
ocuments ded. Any tation are
ed before ews, and and not
views, the mission of e original
ion that a State for ot submit
ed.
extensive ment and commend nsure the
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Thereregar
l Control Audit: Hel Billing Process
No. 1018
ed Resugement
ctive #2: Evacomplete billi
k Performederformed the
Obtained a dubmitted frovaluation of t
Conducted walinics, to valind MBU.
Evaluated proReviews for M
Obtained an efore Medi-C
Obtained andesults, and st
Obtained an uhe Medical R
Medical Billing
clusion audit found tent impropermined by HC
ctive included
. Automatic(MRT Holerrors, omMedi-Cal adequatel
. A quality ahave beenYouth Serand Clinic
. Post-paymsupportedbasis for areviews re
e are no firding efficienc
ealth Care Agency
ults, FinRespo
aluate the adngs.
e following to
detailed undm Behaviorathe frequenc
alkthroughs, idate the pre
ocesses for cMedi-Cal claim
understandinCal and Medi
d reviewed statistical data
understandinReview Teag Unit Coders
that pre-billinr or incomplCA based ond:
c billing holdsds) and code
missions, impbillings andy supported.
assurance pn passed. Frvices), there
c Technical R
ment reviewsd. Also, postadditional traeflect an erro
ndings andcy and effect
y
ndingsonses
dequacy of p
o accomplish
erstanding oal Health Sy of reviews
interviews, ae-billing revie
conducting Cms to determ
ng of work qcare claims a
system repora or metrics.
ng of the tecms in Quals to conduct
ng and post-lete billings. n the progra
s in IRIS thater reviews (Cproper codind claims for.
rocess that rFor certain He are pre-billReviews at th
s are done ot-payment re
aining to prevor rate below
d recommentiveness of p
, Recom
re-billing and
our audit obj
of the pre-bervices andand sample
and reviews ews and pos
Clinic Technicmine if they ar
queues and are submitted
rts that docu
chnical requirity Improvempre-billing an
-payment rev The level
am and reimb
t prompt for Coder Holds)g, and non-
r payment.
re-verifies paHCA programing reviews ue clinic sites
on selected eviews analyvent similar e5% (the indu
ndations forre-billing and
mmend
d post-billing
jective:
illing review Public Hea
sizes.
of related dost-billing paym
cal Reviews are valid and s
holds in IRISd for paymen
ument the m
rements, cerment and Prnd post-billin
views are ad of pre-billinbursing entity
various pre-b)]. These revcomplianceThe review
atients’ Medicms where Musing Medi-C.
paid claims yze claim erroerrors from ocustry standar
r this objecd post-payme
dations
reviews that
process foalth Services
ocumentationment reviews
and Medical supported in
S that requirnt.
medical billin
rtifications anrogram Comg payment re
dequate in hng and posty. Key cont
billing reviewviews are vitprior to sub
ws also help
care eligibilitedi-Cal is bi
Cal Review t
to ensure thors and use ccurring. Curd acceptable
ctive. See ent reviews.
and
t help detect
r billings ans. This inc
n at a samples performed
Review Teaclinic docum
res reviews/a
g process w
nd training nempliance, aneviews.
helping to det-payment retrols noted u
ws [e.g., charal in helping mitting Medip ensure cla
y and that plled (e.g., C
teams (MRT)
hey are accuthis informa
urrently, post-e error rate is
Audit Obje
Page 10
improper
nd claims luded an
e of HCA by QIPC
ms Chart ments.
approvals
work-flow,
eeded by d by the
etect and eviews is under this
rt reviews to detect care and aims are
rior holds hildren & ) in QIPC
urate and ation as a -payment s 5%).
ective #5
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actoe
l Control Audit: Hel Billing Process
No. 1018
ed Resugement
ctive #3: EvaPractice Expegation of duransactional
k Performederformed the
Gained an undwhether: onuthorization uthorizations
Gained an unermination to with written fomployee's laeactivates or
Obtained appwhether they orces systemmay be reuseefore the acppropriate ind
Obtained a lisuties (data erocess.
Conducted walinics, the Quo obtain a d
Health Serviisits/encounteviews. Theiagnostic anate/time, aceviews/appro
clusion audit found ms are ade
egation of du Key contro
Based on discccess to the o add or modmail authoriz
ealth Care Agency
ults, FinRespo
aluate the adpert systems uties, systemaudit trails.
e following to
derstanding oly departmeis in written
s are filed.
nderstanding determine w
ollow-up whenst day of em
r removes the
plication accomeet best p password c
ed; number ocount is lockdividual to re
sting of applentry versus r
alkthroughs, uality Improvdetailed undeces and Pters, pre-billie purpose wnd procedurections takenovals, etc.).
IT applicatioequate in tuties, systemls noted were
cussions withapplications
dify access rzations or wri
y
ndingsonses
dequacy of IT in the area
m edit checks
o accomplish
of procedureent managem
form or com
of procedurwhether: secn an employ
mployment; ane user accoun
ount and paspractices: mhange; numbof concurrentked; length omove accoun
lication usersreview/releas
interviews, avement and Perstanding o
Public Healthng reviews,
was to docume codes, et
n, data valu
on controls ohe areas o
m edit checkse:
h relevant HCincluded the
rights; authoitten authoriz
, Recom
T applicationas of user acs (e.g., data
our audit obj
s for grantingment has themmunicated
res for remourity adminis
yee gives notnd upon notint or user pro
ssword settinminimum pasber of times pt connectionsof lock out pent lock), and
s and reviewse) and acce
and reviews Program Comof medical bh Services,
submissionment applicattc.) and tranues before/a
over the billiof user acces, system en
CA staff and e following: orization is in zations are fil
mmend
controls oveccess (passw
a validations)
jective:
g users accee authority via email; an
oving user acstration is nottice or is to bfication, the
ofile from the
ngs for the fossword lengthpassword mus allowed; nueriod (users length of time
wed access fess to confide
of related dompliance Divbilling proces
starting wn of claims tion edit chensactional aafter and e
ing process ess (passwonforced holds
review of fornly departmewritten form
led.
dations
er the billing word and ac), system en
ss to the appto add or mnd email aut
ccess upon tified promptlybe terminatedsecurity admsystem.
ollowing parah; number oust be changumber of incshould be re
e incorrect lo
for an approential data as
ocumentationvision, and thsses and cowith patient
to the Stateecks (e.g., daudit trails (devents logge
in the IRIS ord and acs/queues, an
rms, proceduent managem
m or commun
and
processes inccount mananforced holds
plications to dmodify accesthorizations o
employee try in writing od; notification
ministrator im
ameters to df days befored before a
correct logon equired to co
ogon count is
opriate segres related to t
n at a samplehe Medical Bontrols for B
registratione, and post-uplicate claidata loggeded - data
and Practiccount manand transactio
ures for grantment has the nicated via e
Page 11
n the IRIS agement), s/queues,
determine ss rights; or written
ransfer or or verbally n includes mediately
determine re system password attempts
ontact an retained.
egation of the billing
e of HCA illing Unit
Behavioral , patient -payment ms, valid
d – user, changes,
ce Expert agement), onal audit
ting users authority mail; and
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l Control Audit: Hel Billing Process
No. 1018
ed Resugement
Based on discccess upon otified in wrierminated; noecurity admin
HCA uses thehe applicatiohose settingsonnections a
ock out periodock), and lenwe reviewed aumber of da
must be chang
RIS and Pracdequate segata.
RIS applicaticcess and caystem enforciagnosis andiagnosis/proc
dentifier) requ
RIS applicatiystem generadata change
modified by th
Practice Expemiting their alculated by
Practice Expentries (user n
e are no find
ealth Care Agency
ults, FinRespo
cussions withemployee trating or verbaotification incnistrator will d
e departmentons (IRIS ans and determallowed, numd (users sho
ngth of time iand determinays before syged before a
ctice Expert gregation of
on controls apabilities, usced billing hod procedure cedure codeuired.
on audit traiated entries es, reviews/ahe end users
ert applicatioaccess an
the applicatio
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dings or rec
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h relevant HCansfer or terally with writcludes emplodeactivate or
tal network ad Practice E
mined the fomber of incorrould be requirincorrect log
ned the followystem forces
a password m
application uduties (data
for the billinsers are onlyolds (each ho
codes, billines, and valid
ls for the bilfor activity (d
approvals, ho, only added
on controls fd capabilitieon based on
on audit trailate) for charg
ommendatio
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CA staff and mination incltten follow-upoyee's last dr remove the
ccount and pExpert). Forllowing settinrect logon attred to contacon count is
wing settings s system pa
may be reuse
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g process iny allowed to vold has to beng rates areMedical Rec
lling processdata logged –old releases)to.
for the billines, valid dia the diagnos
ls for the bige entry and c
ons for this
mmend
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password secr the networngs were aptempts beforct an appropretained. Fowere approp
assword chaned.
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lling processcharge modi
objective.
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curity settingrk account sppropriate: nre the accouriate individuor the passwpriate: minimnges, numbe
g process is ease) and a
ssigned user a for their asfore it can bby the appl
er and FIN (u
omments/nottime, actionsments/notes
ncluded: ascedure codee codes.
s consisted fication.
and
ures for remocurity adminisves notice orupon notifica
ofile from the
gs to restrict asettings, we number of cont is locked,
ual to removeword securitymum passwoer of times p
appropriate access to co
profiles limissigned organe billed), valication baseunique encou
es section cs taken; even
cannot be d
ssigned usees, and billi
of system g
Page 12
oving user stration is r is to be ation, the
e system.
access to reviewed oncurrent length of
e account y settings, rd length, password
including onfidential
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containing ts logged
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No. 1018
ed Resugement
ctive #4: Evms in the are
k Performederformed the
Obtained andpplication so
were adequathanges are erform configillings. These
Obtained and hey address:oftware fixes
Obtained and ddresses therovided by thendor; and o
Obtained and dequate.
Determined wntire system
Obtained andracking repoarticipating in
clusion audit found thup and reco:
HCA has writHCA does nohange reque
Change reSoftware uAdequate End usersOnly apprSoftware iThe impleImplemenDocumentimplemenAffected sA post imp
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valuate the eas of chang
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d reviewed Hoftware includte. HCA doesubmitted to
guration mode change req
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reviewed sae following: dhe vendor isperations doc
reviewed wr
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d reviewed thort from CEn the County’
hat IT generavery for the
tten procedut change the
ests are sent
equests are mupdates recetesting of the
s are involvedropriate patchis implement
ementation oftation tasks ated back-outtation.
systems are bplementation
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oftware agreesupport; procements are p
amples of IRdocumentatios clear and ecumentation
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al controls arIRIS and P
ures for upde underlying to the vendo
managed usieived from the software ud in the testinhes/upgradested during timf new softwaare clearly det procedures
backed up ben review is pe
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f IT general ent and back
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n proceduress and maintey the IRIS o
ctive vendor uch as addinandled interna
ements for IRcedures for provided in a
RIS change reon is providedeasy to use; is provided b
p and recove
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Business Coon Technoloontinuity plan
re adequate Practice Expe
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or. The applic
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mes when prore products iefined and res are develo
efore fixes arerformed.
mmend
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jective:
s for modifyienance to de
or Practice Exfor consider
ng a new conally per HCA
RIS and Pracrequesting stimely manne
equest docud with the fixe
installation dby the vendor
ry procedure
e that a singl
ontinuity Planogy to detenning project
in the areas ert applicatio
RIS and Praccode for IRIScation update
or’s support we reviewed bynducted prior
ed for implemocessing is ss communicaesponsibilitieoped and av
re applied.
dations
ver the IRIS very.
ing the IRISetermine whxpert applicaration. For Intract servicepolicy.
ctice Expert systems softer; and produ
mentation toes from the vdocumentatior.
es to determin
le disk proble
n Componenrmine whethand their sta
of change mon software.
ctice Expert S and Practice procedures
web site (IRIy knowledgear to impleme
mentation. slow or non-eated to all aff
es are assignvailable if pr
and
and Practic
and Practichether the pration code. AIRIS only, He provider) to
to determinetware enhanuct training.
determine wvendor; documon is provide
ne whether t
em does not
nt Deliverableher HCA is
atus.
management Key contro
application ce Expert ans include:
S only). able individuntation.
existent. fected areas ed. roblems occ
Page 13
ce Expert
ce Expert rocedures Any code
HCA does o process
e whether ncements;
whether it mentation ed by the
they were
bring the
es Status s actively
and data ols noted
software. d instead
als.
of HCA.
ur during
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Undeplann Findi SummAs ofBusin DetaiA cureventProgr(1) btestinis coFundadeparCEO/PrepaFunda
l Control Audit: Hel Billing Process
No. 1018
ed Resugement
Additionally, fontract servicertain limitatteps as the atandardized
Software agreeen clearly dtraightforwar
Software docurovided with o use; installrovided by th
Backup and rackup tapesackup schemackup tapestored in secuff-site storag
he storage dystem (IRIS a
HCA is particiubmitted 9%
er this objectning. Our find
ing No. 1 –
mary f July 23, 2
ness Continu
ils rrent and effet of a disastram and taskusiness imp
ng of the planordinating wamental Plartments into /IT purchaseareOC and Ramental Plan
ealth Care Agency
ults, FinRespo
for IRIS onlyce provider) ions of the Iapplication urequest form
eements for defined; procrd; and softwa
umentation fothe fixes fromation docum
he vendor.
recovery wris are periodime allows ths are stored ured, locked e facilities; a
devices are cand Practice
pating in the of the reque
ive, we idending and reco
Need to Co
012, HCA hity Fundame
ective busineter. To this ked the CEO/pact analysisn documents with the Couan Compone
Phase Twoed software RecoverOC n Componen
y
ndingsonses
y, HCA perfofor the billin
RIS applicatpdates noted
m and logs the
IRIS and Prcedures for rare fixes and
or IRIS and Pm the vendo
mentation is p
tten proceducally write tehe system to
in secured, and fireproo
and recovery
configured to e Expert) dow
e County’s buested docume
tified one (1ommendatio
omplete Bus
has completeental Plan Co
ess continuityend, the Co
/IT with mans and develo
and on-goinnty departm
ents (compleo - testing of
to assist wiweb portals
nts.
, Recom
orms configung process. tion (hospitald above. Ase requests.
ractice Experrequesting syd enhanceme
Practice Expr; documentaprovided by
ures includeested to enso be restore
locked andof facilities; bprocedures a
ensure that wn.
usiness contients for Phas
) Control Fn is noted be
siness Cont
ed and submomponents do
y plan is necounty createaging this efopment of bng maintenan
ments to cometion target wf the plan doith the deveand templa
mmend
uration modiThis is a re
l vs. clinic ens these are in
rt address thystems softwents are prov
pert addresseation providethe vendor;
the followinsure that theed to within fireproof fa
backup tapesare documen
a single disk
nuity planninse One. See
inding concelow:
tinuity Plan
mitted to CEocuments for
cessary to end the Countffort. CEO/ITbusiness connce of the plamplete the Pwas end ofocuments. A
elopment of tes and sam
dations
fications (suelatively comnvironment). nternal modif
he following: ware enhancevided in a tim
es the followied by the venand operatio
ng: backupsey can be ut24 hours ofcilities; off-s
s are rotatednted and are
k problem doe
ng project; hoe Finding No.
cerning HCA’
nning Docum
EO/IT about r Phase One
nsure continty of OrangeT divided the ntinuity plan an document
Phase One -2011) and
As part of mthe docume
mples for the
and
ch as addinmplex proces
HCA followfications, HC
vendor supements are c
mely manner.
ng: documendor is clear ons docume
s are taken tilized if requf the incidenite backup t between ontested perio
es not bring t
owever, HCA. 1 below.
’s business c
ments
9% of the . (Control F
ued operatioe Business C
task into twodocuments,
ts. Currently- Business C
to transitionmanaging theentation inclue Business C
Page 14
ng a new ss due to ws similar CA uses a
pport has clear and
entation is and easy ntation is
regularly; uired; the nt; on-site tapes are n-site and dically.
the entire
A has only
continuity
County’s Finding)
ons in the Continuity o phases: , and (2) y, CEO/IT Continuity n County e project, uding the Continuity
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InternalMedicalAudit N
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As ofFundaCEO/
The fo
The aoperadue toother RecoHCA priorit(Phas HealtConcalreadsignifcomp
l Control Audit: Hel Billing Process
No. 1018
ed Resugement
f July 23, 2amental Plan/IT has receiv
Critical BuCritical PrCritical Bu
ollowing docDelegationOrders of RACI (ResLogistics Planning, CommunicCritical BuIncident RIncident R
absence of ations in an eo the compleresource co
ommendatiocontinue to pty to complese One).
th Care Agecur. HCA is dy made thificant progrepletion percen
ealth Care Agency
ults, FinRespo
2012, HCA hn Componenved the followusiness Procerocess IT Depusiness Proce
cuments havens of AuthoriSuccession sponsible, AcTables (suchand Vendorscation Tablesusiness ProceResponse WoResponse Ch
these documeffective andexity of its enmmitments t
n No. 1 participate wte and subm
ncy Manageaware of ths a high pri
ess and hantage from a
y
ndingsonses
has completents documentwing from HCess Listing (ipendency (coess IT Depen
e not been suty
ccountable, Ch as Alternas and Suppos ess Continuiorkflow/Decisecklist
ments may d timely mannnvironment ato prepare a c
with the Counmit the Busine
ement Respoe importanceority. Since
as submittedbout 9% to o
, Recom
ed and submts to CEO/IT.CA: ncomplete)omplete) ndency Reco
ubmitted by H
Consulted, Inate Facilities,rting Departm
ty Strategy Idsion Matrix
impede HCAner in the ev
and the numeconsolidated
ntywide Business Continuit
onse e of the Buse the compled additional over 72%.
mmend
mitted about. The HCA s
overy Strateg
HCA:
nformed) and, IT Dependments)
dentification
A from contvent of a disaerous prograd business co
ness Continuty Fundamen
siness Contietion of the
documentat
dations
t 9% of thestatus is:
gies Identifica
d Team Respencies, Vital
inuing/resumaster. HCA’sms which it hontinuity docu
uity planning ntal Plan Co
nuity Fundaaudit reviewtion to CEO
and
Business C
ation (incomp
ponsibilities/Dl Records, W
ming normal s delays apphas to coordument.
project and mponents do
mental Plan w, HCA IT hO IT increa
Page 15
Continuity
plete)
Detail Workforce
business pear to be inate and
make it a ocuments
and has has made asing the
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ObjecduplicHCA WorkWe p
1
2
3
4
ConcOur aWe aidentiand pgener FindiClaim SummSinceDeceCal abecau(Cont DetaiAccordocumservicservicissuecontinclaimsettleentereDece
l Control Audit: Hel Billing Process
No. 1018
ed Resugement
ctive #5: Dcation of worcan reduce t
k Performederformed the
. Inquiry of billing, incHCA’s Qu
. Auditor obintake/regExpert, an
. Observatio
. Assessedpayment rrequest ofstill necesended.
clusion audit found tassessed HCified three (3post-billing rrate manage
ing No. 2 –ms
mary e the Integritmber 2010, nd Medicareuse HCA’s ctrol Finding
ils rding to HCmenting servces in 1990ces, which re and notifiednued in subss for previou
ement was reed an Integmber 2007 th
ealth Care Agency
ults, FinRespo
Determine if rk or backlogthe extent of
e following to
f managemecluding site uality Improve
bservations aistration, pa
nd billing proc
on and inqui
HCA’s metreviews to def HCA manag
ssary given th
here were nCA’s method3) Control Fireviews of sement reports
– Pre-Billin
ty AgreemenHCA continu
e claims. Theurrent billing )
CA, billing fovices performs, they erroesulted in ind HCA of thesequent billinus years. T
eached in 200grity Agreemhrough Dece
y
ndingsonses
the medicags). Includedpre-paymen
o accomplish
nt and staff visits at fou
ement and P
and walkthrotient visits/ecesses in the
ry for eviden
hodologies (etermine if thgement to evhat the Integr
o significant dology and cindings whe
select types s. Our three
g and Post
nt between ues to performere is an opperror rate is
or Medicare med and aponeously useadvertent ov
e concern; hgs. Then the
The investiga07, resulting ent with the
ember 2010.
, Recom
l billing prod in this objent and post-bi
our audit obj
responsibleur County-oprogram Com
oughs of theencounters, ie Medical Bil
ce of backlog
(e.g., frequeney can be m
valuate whethrity Agreeme
backlogs orcontrols ove
ere HCA can of medical findings and
t-Payment
HCA and thm extensive portunity to re
less than 1%
Behavioral plicable cod
ed the sameverbilling. Inowever the e Federal Goation identifiein HCA pay
e Office of
mmend
cesses areective is an ailling reviews
jective:
e for providinperated clinic
mpliance (QIP
e medical billnputting tranling Unit.
gs and duplic
ncy, sample odified. We her the 100%
ent with the O
r duplication er pre-billing
modify its cobillings, and
d recommend
Reviews fo
he Office of pre-billing ane-evaluate pe%, which is u
Health Servding. When e billing codn 2000, Fedeissue did noovernment coed billing erring $7 millionInspector G
dations
efficient anassessment s on select m
ng medical scs, the Med
PC) Division.
ling processnsactions int
cation of wor
sizes) over performed th
% sample sizOffice of the I
of work in thand post-pa
ontrols in cond evaluate thdations are n
or Behavior
the Inspectnd post-paymerforming theunder the ind
vices is uniqHCA began
de for Medi-eral Governmot get immedonducted anrors and resn as settlemeeneral for t
and
nd effective to determine
medical billing
services anddical Billing U
, starting witto IRIS and
rk.
r pre-billing ahis assessme
ze of the revienspector Ge
he areas undayment revienducting pre-he ability footed below:
ral Health S
tor Generalment reviews ese extensiveustry standa
que and parn billing for Cal and/or
ment noted tdiately addres investigation
sulted in litigent. In addithree years,
Page 16
(e.g., no e whether gs.
d medical Unit, and
th patient Practice
and post-ent at the ews were neral has
der audit. ews, and -payment r IRIS to
Services
ended in on Medi-
e reviews ard of 5%.
rticular in Medicare Medicare the billing ssed and n on paid
gation. A tion, HCA
effective
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InternalMedicalAudit N
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UndeMedi-adequInspeAgree To strecrupractiextenless indicaapprolevelsbecau Now paymproce
1)
2)
l Control Audit: Hel Billing Process
No. 1018
ed Resugement
er the Integri-Cal claims auately suppo
ector Generaement as bot
rengthen inteited Certifiedice to reduce
nsive billing rthan 1%.
ating the termoach by cons (e.g. MRT use of the fis
with the Intement review esses for con
System HoldHCA may Patients/clieclaims are Health Servare reviewereviewer beclaims requImprovemenobjectives odeterminatiobetween theconsider the
Conducting Currently, thall Medicarereview, the reviews baspayment rev RecommenHCA evaluacontinue theshould evaluMedicare clare below th Health CareConcur. Duanalyzed anMedi-Medi completes pMedicare cla
ealth Care Agency
ults, FinRespo
ty Agreemenand post-payorted. (Noteal determineth are funded
ernal controld Coders toe risk and to review proceIn June 201
m of the Integducting pre-Chart Revie
scal impact of
egrity Agreemprocesses.
nsideration of
ds for Proceswant to as
ents eligible submitted to
vice providedd prior to su
efore the clauire not onlynt & Prograof these revion whether oese two reviee necessity o
Pre-Billing ahere are three claims prioerror rate w
sed on a desview on Med
ndation No. 2ate its pre-bie current prouate its pre-baims with co
he industry st
e Agency Mauring the cound changes hClaims has post-paymenaims due to t
y
ndingsonses
nt, HCA perfyment auditse: Although ed that Medd by the Fede
s and ensuro perform bi
ensure billinss, the curre
11, HCA recgrity Agreem-billing and pew, Charge Af billing error
ment ended, HCA sho
f the following
ssing Medi-Mssess the ris
for both Meo both Medi. Currently, bmitting themim is submit
y a MBU Com Complianiews are diffor not the bews. Since tof the MRT ho
and Post Payee Certified Cor to submittiwas less thanignated samicare claims,
2 lling review pcess which rbilling and poonsideration tandard in th
anagement urse of this ahave alreadybeen modifi
nt reviews onthe conserva
, Recom
formed pre-bs on all Medthe errors r
di-Cal claimseral governm
e complianceilling reviewsng errors areent External ceived a lette
ment had endepost paymenAudit Reviewrs on the Cou
HCA has anould evaluatg:
Medi Claimssk of remov
edicare and care (primarthere are bum for reimbutted to the Soder Reviewnce Chart Rferent, we n
billings can bthe Coder Rold for these
yment ReviewCoders conduing them for n the industrple size, or c, but not perf
process for Mrequires bothost payment of frequencye number of
Response audit, the roley been impleied to includn a sample ative approac
mmend
billing reviewdicare claimsresulted froms should al
ment.)
e, HCA estas, and adop within the inQuality Revier from Officed. Howevent reviews ofw, MBU Codunty.
n opportunityte the pre-b
ving the MMedi-Cal arery) and Meduilt-in systemursement. AState for adj
w, known as eview, knowoted that th
be submittedeview supersclaims.
ws on a Samucting pre-bilr billing. Becry standard. consider conform both rev
Medi-Medi Ch reviews at Mreview procey and samplerrors identi
e of QIPC anmented. Thede only the basis. HCA
ch of the age
dations
ws on 100% s to ensure tm Medicare so be inclu
blished the Opted a morendustry standew showed ce of Inspec
er, HCA contif all Medica
der Review,
y to modify itbilling and p
RT hold fore referred as
di-Cal (Secon holds in IRISll holds havejudication. T
Coder Holdwn as MRT e Coder Re
d in the evesedes Chart
ple Basis ling and poscause of the HCA shouducting eithe
views on the
Claims and dMBU and QIess for Behave sizes of thfied.
nd MBU in thee pre-billing MBU Coder
A will continuncy.
and
of the Medihey were prclaims, the
uded in the
Office of Come conservativdard. BecauHCA’s error ctor Generalinued its conre claims atand a QIPC
ts pre-billing post-paymen
r Medi-Medis Medi-Medindary) for BS to ensure
e to be cleareTherefore, Md, but also aHold. Althoview makes nt there areReview, HC
st payment ree enhanced pld assess coer a pre-billinsame claim.
determine thePC. In additvioral Health he reviews g
e review proreview procer review. Que to review
Page 17
icare and roper and Office of Integrity
mpliance, ve billing
use of the rate was officially
nservative t different
C Review)
and post nt review
i Claims. i. These
Behavioral all claims ed by the
Medi-Medi a Quality ough the the final
conflicts CA should
eviews on pre-billing onducting ng or post
e need to tion, HCA Services iven they
cess was ess for all
QIPC now 100% of
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InternalMedicalAudit N
DetaileManag
Findi SummThe progrthe Frespopaymreceiv DetaiDurinsampExpeclaimsampeffectwas rof the Thereall BHadequshoulamouthey t RecoHCA revisiefficie HealtConcincludmonitsampbeen post-pfocus
l Control Audit: Hel Billing Process
No. 1018
ed Resugement
The post-bilerror rate. Hhappen in Jis found thabe modifiedabove 2%, error rate reabout 10%.
ing No. 3 –
mary Medical Billiram ~ FamilyFPACT claimonsible for pe
ment review isved from Jan
ils ng our audit,ple of all patiert. Claims ps, this result
pling methodtiveness of threviewing paye review coul
e are three cHS Medicareuately suppold be conducunt to enhantook correctiv
ommendatiocontinue to on is needeency of the p
th Care Agecur. The posde a reductiotored and at ple size will b
moved frompayment res
s on their core
ealth Care Agency
ults, FinRespo
lling review pHowever, as January 2013at the error ra to a samplethe sample
emains at or
Post-Paym
ing Unit (MBy Pact Progra
ms. Currentlyerforming ths behind schnuary 1, 2011
we observeents from theertaining to tts with the redology may he review. Oyments for thd be improve
coders at MBe claims andorted. An evcted to detece effectivenve action to m
n No. 3 evaluate thed to limit theost-payment
ncy Managest-payment reon in the samany time thebe adjusted the staff responsibilities.e responsibil
y
ndingsonses
process has significant o
3, 100% of Mate is consise size of abosize for thatbelow 2% fo
ent Review
BU) performam (FPACT)y, there are ese reviews
hedule. The 1 through Ma
ed that the e paid report,the selected eview percen
result withOur observathe period fored if the sam
BU responsibd a sample ovaluation of
ermine if reviness. Whenmodify the po
e current pose sample sizt reviews.
ement Respoeview procesmple size fore error rate sh
accordingly.sponsible for This has elities allowing
, Recom
also been anr critical cha
Medicare servtently at 2%
out 20%. Hot program wior six month
ws for Public
ms post paym). MBU Codthree coder on a quartelast review c
arch 31, 2011
MBU Coder, known as Cpatient are r
ntage being mh an uncontion was conr January 1, 2
mple size is co
ble for conduof PHS Medithe current pision is need we notified ost-payment
st-payment reze at a reaso
onse ss for PHS cr Family Pacthows a stead. In additionthe review tonsured the s
g for all revie
mmend
nalyzed and nges occur ivices will be or less, the
owever, if thell be adjustes, the sampl
c Health Ser
ment reviewsders performs within the erly basis. Wconducted in1. (Control
r uses a samCharges-Paymreviewed. Smore than 2
ntrollable samducted in Oc2011 throughontrollable at
cting pre-billi-Cal claims post-paymended to limit the MBU ofreview proce
eview procesonable amou
claims has bt from 20% tdy increase an, the proceso the MBU ITstaff responsws to be com
dations
will be adjusin the billing reviewed popost-payme
e error rate aed accordingle size will a
rvices Claim
s for one Ppost paymeMBU and o
We were infn October 20Finding)
mpling progrment Profile ince a patien0%. Also, thmple size actober 2011 h March 31, t a reasonabl
ing and postto ensure th
nt review prothe sample f this finding ess.
ss for PHS cunt to enhan
been modifieto 10%. Thisabove the stass to determT Systems Tesible for the pmpleted on a
and
sted to reflecprocess, suc
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Page 18
ct the low ch as will When it ocess will increases on, if the reased to
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