Internal AuditingOperational Audits vs Clinical Audits

Presenters:

Nick Borges, Lifespan Corporate Compliance

Scott Brady, Lifespan Corporate Compliance

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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

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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

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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

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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

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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.

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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….

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Differences and Similarities Summary

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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

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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

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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.

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Adaptability and Covid-19

Covid-19 is the ultimate test of adaptability.

❑ Industry Level

❑ Organization Level

❑ Personal Level

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Adaptability and Covid-19 Cont’d

How did we adapt to working during Covid-19?

_ Working Remotely

_ Technology

_ Audit Adaptations

_ Personal Adaptations

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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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