Emergency Department Elizabeth Lowry, Director, Internal Audit Darlene FitzPatrick, Director, Internal Audit Bon Secours Health System, Inc.
ED: Performing a Value-Added Audit Understanding the structure & function of the ED Understanding the importance of the ED Planning the audit Performing the audit Communicating the results
Understanding the structure and function of the Emergency Department
About the ED The Department The People The Processes
About the ED: The Department Type Full service 24/7 Designated Trauma Center Specialty (Peds, Women s, Chest Pain) Urgent Care ( doc in the box ) Reporting Relationships Directly to Operational Leader Directly to Nursing Leader
About the ED: The People Physicians Management (VP, Director, Supervisors, etc.) Nursing, and Pt. care staff Family The Patient Volunteers Ambulance Services, Police Ancillary services staff (registrars, lab, X-ray)
ED Physicians What Do You Need to Know? Contract National Vs. Private Employed Private Physicians Coverage Type Credentialing Mid Level Providers (NPs and PAs) Information Needed by Physician
About the ED: The Processes Access Diversion Marketing Programs (Wait Guarantees) Front End Triage Registration Back End Patient Care (services, tracking) Documentation Charge Capture Discharge/Disposition
About the ED: The Processes Alternative Processes Ancillary Services (Pharmacy, Lab, Radiology) Admit/Observation Prep for OR Performing procedures Off hours infusion clinic Quality and Preparation Hospital and Community Disaster Planning Rescue Squad, Police, Fire, Social Services relations, reporting, education Training Quality Assurance/Dashboards
Triage Scenario
Understanding the Importance of the Emergency Department
Importance of ED Size and location (In hospital, in community) Volume (day, month, year) Visit level acuity (1 5) % outpatients to inpatient admits % of Hospital Admissions from ED Growth Trends and Expectations Payor Mix Trends Customer Satisfaction Community Changes
Planning the Audit
Key Stakeholders Physician Group Management (VP, Director, Etc.) Nursing Emergency Department Corporate Responsibility, Corporate Compliance Risk Management Legal (In House)
Applicable Research EMTALA Regulations OIG Workplan HIPAA/Security/Privacy State and Local Regulations Internal Policies/Procedures/Practices
Scoping the Audit Identify key risks and processes Identify the focus of the audit (Coding, IS, Operations) Identify the type (system wide, focused, etc.) Timeline Considerations Determine communication plan Define the reporting format
Identify Key Risks Identification & Prioritization Based On: Interviews with management & other key stakeholders Annual risk assessment (why it made the audit plan) Results of research performed (new or existing regs, policies and procedures, etc.)
Identify Key Processes Select Process(es) to be reviewed Front End Back End Administrative Interdepartmental Revenue Cycle
Identify the Focus Charge Capture & Coding Reviews Visit levels, chart documentation, procedures Financial/Operational Complying with internal policies and procedures Compliance EMTALA, OIG Workplan, JCAHO, HIPAA IS Interfaces, Access Security Management
Identify the Type of Audit System Wide All ED s in your health system, concurrent or non concurrent Focused One specific risk area (i.e. EMTALA) Single Entity Only 1 ED in your health system Team Approach Single team travels to each location
Timeline Considerations Availability of stakeholders Work schedules/vacations, management turnover Other Operational Initiatives System implementations, construction, program implementations External Reviews JCAHO, Federal/State auditors, consultants Audit plan scheduling Timeliness of response to data request
Communication Plan Determine auditee point of contact Determine frequency of audit status communication Determine method of communication (phone call, email, face to face) Outline full audit process (planning, testing, reporting, wrap up, client survey)
Reporting Format Traditional/Formal Audit Report Scorecard Assessment With or Without a System Wide roll up Memorandum Attorney Client Work Product Whitepaper
Performing the Audit
EMTALA Testing EMTALA signage is not posted in the ED. Signs may not contain all required information. You have the right to receive within the capabilities of this hospital's staff and facilities: 1. An appropriate medical screening examination 2. Necessary stabilizing treatment (including treatment for an unborn child) if necessary 3. An appropriate transfer to another facility even if you cannot pay or do not have medical insurance or you are not entitled to Medicare or Medicaid 4. The hospital does participate in the Medicaid program. Via a physical walk through, observe whether signs are posted in the appropriate areas and contain the required information. Signs must be in a place or places likely to be noticed by all individuals entering the ED; as well as those individuals waiting for examination and treatment (e.g., entrance, admitting area, waiting room, treatment room). The signs in the waiting area need to be clearly visible from at least 20 feet away.
EMTALA Testing Cont. The ED does not maintain a list of On Call physicians to provide treatment necessary to stabilize an individual with an emergency medical condition. 1. Determine if the ED maintains an on call list of physicians. Who is responsible for maintaining this list? 2. Document the procedures for using on call physicians. 3. Document how the ED monitors and reports the on call physician s response time for issues. 4. Are the responsibilities of the oncall physicians defined in the Medical Staff By Laws?
Coding Integrity Testing Code assignment is not accurate. Review sample of medical records to determine if all assigned codes are: Supported by medical record documentation, Compliant with Official Guidelines for Coding and Reporting, Consistent with official guidance for code selection, Inclusive of all conditions and procedures defined by the Uniform Hospital Discharge Data Set (UHDDS) as being reportable, and Sequenced appropriately.
Coding Integrity Testing Cont. Admit Status Order is not in Compliance with Regulatory Guidelines. Select a sample of patients to compare documented admit status order against regulatory guidelines and verification of status billed. Discharge Disposition code does not match the supporting documentation in the record. Select a sample of patients to compare documented discharge disposition against coded/billed discharge disposition status.
Charge Integrity Testing Documentation in the medical record does not support the charges billed. Obtain a sample of patient medical records, itemized bills, claim forms, and remittance advices to determine if charges billed are clearly supported by documentation in the medical record. Charge capture is not complete and accurate. Obtain a sample of patient medical records, itemized bills, claim forms, and remittance advices to determine if charges are complete and accurate. Review policies and procedures and other internal controls to ensure that they are designed to ensure complete and accurate charge capture.
Charge Integrity Testing Cont. Modifiers are not applied to charges appropriately. Obtain a sample of patient medical records, itemized bills, claim forms, and remittance advices to determine if modifier application is complete and accurate. Review internal controls to ensure that processes are in place to ensure that modifiers are applied appropriately.
Communicating the Results
Communicating Results Preliminary Opportunities Identify Leading Practices Draft Report/Exit Conference Realistic Recommendations/Buy in Opinion/Conclusion Cc. List Audit Committee Communication Expressing Appreciation Auditee Survey