Briefing: MSA Compliance Audits Date: 23 March 2007 Time: 0800 - 0850

1. Briefing: MSA Compliance Audits Date: 23 March 2007 Time: 0800 - 0850

2. Objectives • Understand the basic elements of a Compliance Plan • Understand why being compliant is important • Understand why Auditing and Monitoring is important • Know where to find your Minimum Internal Controls • Know how to perform a self-audit

3. Compliance What is Compliance? • Compliance is an oversight process which requires employees to conduct their duties in an honest, ethical and professional manner Why is Compliance important? • Behavior that is not consistent with ethical business practices places your facility at risk for penalties, negative publicity and loss of public trust Compliance simply means following the rules and regulations of your business.

4. Compliance Program Elements • An Effective Compliance Program has 7 Elements • Element 1 – Development of Compliance Policies and procedures, including standards/code of conduct • Element 2 – Designation of a Compliance Officer and a Compliance Committee • Element 3 – Appropriate Training and Education • Element 4 – Development of Open Lines of Communication • Element 5 – Responses to Detected Deficiencies • Element 6 – Auditing and Monitoring • Element 7 – Enforcement of Disciplinary Standards

5. Audits • Element 6 – Auditing and Monitoring • Importance of Auditing and Monitoring • Conducting regular audits enables you to identify and promptly rectify any potential compliance violations • Types of Compliance Audits • External – Requesting MTF personnel external to the UBO to evaluate your operation • Internal – You or other UBO personnel evaluating your operation • Claims Specific – Randomly pulling paid/closed claims to determine if the entire revenue cycle process was correct (compliant)

6. External Audits • External Audits • The DoD Compliance Audit Checklist should be completed at least quarterly by a non-UBO officer, NCO in the grade of E-7 or above, or a GS-7 or above • Sample Questions: • Does the MSAO perform an unannounced audit of all funds entrusted to permanent cashiers at least once a month? • Are charges/claims reviewed prior to submission to ensure they are “clean”? • Is the separation of duties (biller, cashier, etc.) adequate to protect cash receipts? -Continued-

7. External Audits • Sample Questions: • Are all checks received stored in a safe, logged into a control register and deposited within 24 hours or the next business day? • Are both inpatient and outpatient Notify Rosters printed and worked (cleared) daily? • Are bills submitted timely and with all required documentation to the proper payer? • Are accounts receivable reports routinely reviewed and are processes in place to ensure accurate and timely corrections are made to accounts? • Is the current copy of the cosmetic surgery estimator tool (CSET) being used correctly?

8. Internal Audits • Internal Audits • The minimum internal controls cited in 6010.15M – UBO manual should be reviewed by you frequently • Chapter 3, Medical Services Accounts • C3.7, Minimum Internal Controls • Chapter 4, Third Party Collection Program • C4.11.3, MSA officer Minimum Internal Controls • Chapter 5, Medical Affirmative Claims • C5.3.6, Internal Control of funds • You can use a modified version of the DoD Compliance Audit Checklist or create your own

9. Objectives • Claims Audits • Randomly pulling paid/closed claims to determine if the entire revenue cycle process was correct is another means of ensuring that you are compliant • Areas of concern • PATCAT assignment • Responsible/Billable Party • Medical Record Documentation • Diagnosis and Procedure Codes • Charges/Rates • Posting Collection • Closure/Transfer

10. Additional Information Reviewer: _______________________________ MSA CLAIM REVIEW WORKSHEET Date: ___________________________________ Claim Status: Open / Closed / Transferred 1. PATIENT INFORMATION PATIENT NAME: ____________________________________________ SSN: __________________ PATCAT: ______________ DOB: ______________ AGE:________ MSA PATIENT? Y / N / Unknown CLAIM TYPE: TPC / MSA / MAC / Unknown 2. INSURANCE INFORMATION / N/A NAME: _____________________________________ TYPE: MedRep / MedSupp / Fee for Service / POS / PPO / HMO / EPO / Medicare / Medicaid / Workers Comp / Auto / Other _____________________ BILLING INFO ON UB-92 /CMS 1500 CORRECT? Y / N 3. DATE AND TYPE OF SERVICES DATE(S) OF SERVICE: ___________________ to ____________________ FY _________ SERVICE: IP / OP / APV / LABS / RADS / OBS / AMBULANCE / RX / T-CON / ____________ 4. OUTPT - DO DX, CPT/HCPCS, E/M CODES MATCH DOCUMENTATION? Y / N : No Record / No Diagnosis/ No Treatment / ________________________________________________ PROPER RATES CHARGED? Y / N / __________________________________________________ APPROPRIATE REVENUE CODE(S) USED? Y / N / N/A/ _________________________________ Other Comments: ______________________________________________________________________ Coding Reviewed by _____________________________________________________________________ 5. INPT – DO ICD-9-CM DIAGNOSIS AND PROCEDURE CODES MATCH DOCUMENTATION? Y / N _________________________________________________________________________________ IS THE DRG CORRECT? Y / N / ____________________________________________________ RATE CHARGED: INPT DRG __________ INPT AMOUNT BILLED: _____________________ RWP ____________ X FY ____ ASA ______________ = $ _____________ MATCH? Y / N APPROPRIATE REVENUE CODE(S) USED? Y / N / N/A / ______________________________ Other Comments: ______________________________________________________________________ Coding Reviewed by: ____________________________________________________________________ 6. SUBSISTENCE/FMR: FY __ RATE $___________, BILLED RATE: $ _________ , MATCH Y / N 7 PAYMENT REC’D: $_________________________ BALANCE: $ _________________________ PAYMENT ACCOUNTED FOR PROPERLY? Y / N / __________________________________ PT BALANCE BILLED: $_____________ DUE PROCESS: _______________________________ BALANCE $____________________, TRANSFERRED TO: ________________________________ TRANSFER ACCOUNTED FOR PROPERLY? Y / N 8. Required Action: Re-Bill / Refund / Transfer / Close / None / Other ___________________________ _______________________________________________________________________________________

11. Quiz • How many elements are there to an effective Compliance Program? • Which element is Auditing and Monitoring? • Why is it important to perform audits?