internal auditing operational audits vs clinical audits
Post on 23-Oct-2021
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Internal AuditingOperational Audits vs Clinical Audits
Presenters:
Nick Borges, Lifespan Corporate Compliance
Scott Brady, Lifespan Corporate Compliance
1
Presentation Objectives
❑ Explore the differences and
similarities of Operational
and Clinical audits.
❑ Discuss how leveraging past
experiences can enhance
future auditing.
❑ Highlight the value of being
adaptable in an ever-
changing healthcare
environment.2
Why Audit??
Conducting Internal Monitoring and Auditing is one of
the seven Fundamental Elements of an Effective
Compliance Program
To provide independent assurance that an organization’s
risk management, governance, and internal control
processes are operating effectively.
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Presenter Background Information
Scott Brady
❑ Physical Therapist
❑ Rehabilitation Management
Experience
❑ Clinical Informatics
❑ Clinical Compliance
Auditor for Lifespan
Nick Borges
❑ Accounting Education
❑ Accounts Payable
Experience
❑ Financial Auditor for the
State of Rhode Island
❑ Operational/Compliance
Auditor for Lifespan
4
What are the Differences Between Operational and Clinical Audits?
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What are the Differences Between Operational and Clinical Audits?
Differences:
1. Audit Topic Focus: Logistics vs Healthcare Focus
2. Scope of Audits: Broad vs Narrow
3. Audit Goals: Process Risk vs Regulatory Risk
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Audit Topic Focus: Logistics vs Healthcare
Clinical Audits
❑ Focus on Clinical Operations
at risk of payment error or
governmental scrutiny
❑ Use of Unbundling Modifiers
(-59)
❑ Outpatient Claims Greater than
$25,000
❑ PEPPER Outlier review
Operational Audits
❑ Focus on Logistic and Business
Operations
❑ Payroll
❑ Purchasing
❑ Finance
❑ Human Resources
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Scope of Audits: Broad vs Narrow
❑ Broad Audit Scope: Operational audits tend to focus
on entire process’s from beginning to end and encompass a
wider audit scope.
_ Example: Vendor Management or Cafeteria Audits
❑ Narrow Audit Scope: Clinical audits tend to focus on
individual programs with specific requirements including
identifying processes hindering compliance.
_ Example: Inpatient Rehabilitation Facility Billing Requirements
8
Audit Goals: Process vs Regulatory Risk
Clinical
❑ Focus on clinical
documentation supporting
submitted claims.
❑ Process assessment to
identify factors which may
create lack of control.
❑ Recommendations to
enhance compliance with
regulations and mitigate
risk.
Operational
❑ Focus on identifying risks
within a process.
❑ Identifying controls and/or
lack of controls within a
process.
❑ Make recommendations to
mitigate risk and enhance
control environment.9
What are the Similarities Between Operational and Clinical Audits?
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Similarities:Audit Process/Flow
❑ Risk Assessment
❑ Planning
❑ Fieldwork
❑ Reporting
❑ Follow Up
11
Similarities:Risk Assessment
The Foundation of the Audit Process
Risk Assessment:
What are industry risks and where are we potentially vulnerable?
❑ Senior Management Surveys
❑ Operational Management Interviews
❑ Regulatory Publications
❑ Audit Staff Input
❑ External Articles
12
Similarities:Planning
“By failing to prepare, you are preparing to fail.” – Ben Franklin
Planning:
❑ What do I need to know to perform this audit (research),
❑ What is our scope,
❑ Do federal, state, company policies, best practices exist,
❑ Who do we meet with and who is our point of contact,
❑ What systems may we need access to,
❑ Have there been prior audits of this area.
13
Similarities:Fieldwork, Reporting, and Follow Up
Fieldwork:
❑ Interviews
❑ Testing
❑ Communication with Auditees
❑ Review of testing with
Auditees
Reporting:
❑ Outline, Draft Report, Final
Report
❑ Management Responses to
Draft Report
Follow –Up:
❑ Are the auditees putting our
recommendations into
action.
❑ Do the recommendations
need to be altered to reflect
operations?
❑ When can we close this
audit….
14
Differences and Similarities Summary
15
Clinical
Audits
Operational Audits
Audit
Process
Leveraging Your Past Experiences
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Leveraging Your Past Experiences
“Those who fail to learn from history are doomed to repeat it”
- Winston Churchill
❑ Diverse experience affects your perspective and can help in identifying or resolving issues.
❑ Every job, every audit, every audit step, is an opportunity to learn something new or refine your technique.
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Accounts Payable to Operational/Compliance Auditing
Accounts Payable:
❑ Reconciling
❑ Approvals Auditing
❑ Time Management
Governmental Auditing:
❑ Regulatory based auditing
❑ Audit Process
❑ Interviewing skills
❑ Workpaper skills
❑ More Reconciling
❑ Time Management
Operational and Compliance
Auditing (Lifespan)
❑ Process Auditing
❑ Refinement of Audit Process and
Auditing/Time Management skills.
❑ Fraud Auditing
❑ IT System Auditing
❑ 7 Elements of a Compliance Plan
❑ Even More Reconciling
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Rehabilitation to Compliance Auditing
Rehabilitation Professional:
❑ Physical Therapist
❑ Providing Patient Care
❑ Time Management
Rehabilitation Management:
❑ Quality Assurance /
Improvement
❑ Process development and
implementation
❑ Awareness of Regulations
❑ Managing professionals
Clinical Audits and Compliance
Auditing (Lifespan)
❑ Clinical Auditing – assessing
appropriateness of
❑ Coding
❑ Billing
❑ Supporting clinical documentation
❑ Associated processes
19
Summary of Leveraging Your Experiences
❑ Understanding of Auditing Practices/Business
Operations
• How to plan, conduct, report, and follow-up.
• Conducting audits on various areas increased my exposure and
changed how I approach future audits.
❑ Understanding of healthcare operations
_ Clinical workflow
_ Documentation of clinical services
_ Quality Assurance to facilitate compliance
_ Being an auditee 20
The Skill We all Need
21
Why Be Adaptable?
“Intelligence is the ability to adapt to change” – Stephen Hawking
❑ Healthcare can and does change rapidly.
❑ Practices
❑ Regulations
❑ Business and Clinical Operations
❑ General Trends
❑ To stay relevant and to continue to add value to our customers we
as auditors need to be able to adapt to a rapidly changing
environment.22
Adaptability Continued
Ways to Adapt in an evolving industry:
❑ Stay up to date with regulations and best
practices.
❑ Don’t let your less used auditing skills get rusty.
❑ Read professional journals and published
articles.
❑ Cross-train on skills you currently don’t possess.
23
Adaptability and Covid-19
Covid-19 is the ultimate test of adaptability.
❑ Industry Level
❑ Organization Level
❑ Personal Level
24
Adaptability and Covid-19 Cont’d
How did we adapt to working during Covid-19?
_ Working Remotely
_ Technology
_ Audit Adaptations
_ Personal Adaptations
25
Summary of Presentation Goals
❑ Differences and Similarities of Operational and
Clinical Audits
❑ How leveraging your prior experiences can
enhance your auditing.
❑ Why we should all prioritize being adaptable in an
ever-changing environment.
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Questions/Comments?
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