Case Studies: Corporate Compliance
Risk Assessments
Internal Audits
Risk Assessment
Radiology Center Risk Assessment
BlickenWolf was engaged by an integrated healthcare provider to perform
an overall risk assessment of their Radiology Department (the Department),
related to departmental operations, the radiology information system
(RIS), and billing/coding compliance.
Our assessment included an overall review of the revenue cycle from scheduling through charge capture and billing as it relates to the Department. We performed a thorough evaluation of the operations of the Department by conducting interviews with the physicians, technicians, and staff and performing on-site observations of the daily functioning of the Department.
Our primary objective was to identify specific areas of risk and vulnerability in their departmental operations, RIS, and billing/coding process. From this evaluation, we made recommendations for improved operational efficiencies and advised on specific process improvement initiatives.
Fetal Diagnostic Center Risk Assessment
BlickenWolf was engaged by a large integrated healthcare delivery network
to assess the status of their outpatient high-risk fetal diagnostic
center as it relates to federal, state and private payer regulatory
compliance. We performed a thorough evaluation of the operations
of the center by conducting interviews with the center physicians,
and staff, performing an on-site observation of the daily functioning
of the center and “shadowing” the medical director in both the outpatient
center and in the adjacent hospital.
Our primary objective was to identify specific areas of compliance risk and vulnerability in their operations, billing and coding, and documentation processes. From this evaluation, we made recommendations for improved operational efficiencies and advised on specific procedural coding initiatives. We further developed a comprehensive, detailed Policy and Procedure Manual that specifically addressed individual medical and diagnostic procedures performed in the medical specialty clinic. Inherent in this process was the establishment of quality standards of practice.
As the outpatient fetal diagnostic serves as the obstetrical resource to a very large population of the medically underserved, the significance and ramifications of this project are of paramount importance to this healthcare network.
Home Health Risk Assessment/Compliance Plan Implementation
BlickenWolf was engaged to perform a risk assessment and develop a
complete compliance program for a pharmacy and durable medical equipment
supplier. We conducted interviews of staff and management. We also
analyzed operations and records. We noted potential areas of risk
and presented the finding to the management. We also developed policies
and procedures that addressed the risks and provided guidance for
the management and employees of the company.
Internal Audit
Outpatient Psychiatric Clinic Internal Audit
BlickenWolf was engaged by a large integrated healthcare delivery network
to perform a compliance evaluation of their outpatient psychiatric
clinic. Upper management had raised concerns regarding the accuracy
and validity of the operations, billing and coding, and documentation
process of this outpatient psychiatric clinic.
We conducted a detailed medical record audit to determine the status of the clinic as it relates to federal, state and private payer regulatory compliance, and to identify specific areas of compliance risk and vulnerability. Based on the medical record audit, we developed a comprehensive Policy and Procedure Manual outlining procedures to enhance proper documentation and billing practices and to promote operational compliance.
The development of the Policy and Procedure Manual involved scrutinizing the entirety of the mental health regulatory environment for practical and generally accepted procedural guidelines, taking into account particular statutes, rules, regulations, and program instructions to create a high quality standard of care for outpatient mental health.
Ambulatory Clinic Internal Audit
BlickenWolf was engaged by a health system (the System) to perform
an internal audit of the System’s four outpatient clinics. The audit
consisted of both an operational review of the revenue cycle processes
and procedures in the four clinics and a medical records analysis
for accuracy related to documentation, coding and billing.
We interviewed individuals representing administration, patient service, coding and billing; observed processes; and reviewed documentation. We documented investigative findings and recommendations. We also worked with System management to prioritize recommendations, and developed an implementation and response plan.
Counseling Center Internal Audit
BlickenWolf was engaged by a major healthcare organization to conduct
a review of the provider billing practices for the organization’s
counseling center. We conducted a review of medical records that
revealed problems with practitioner documentation, ICD-9-CM code
assignment, and CPT code assignment. We also discovered that the
organization was conducting a billing practice that could affect
the funding received from a federal program.
Our findings resulted in management implementing standards to improve billing, coding and documentation practices. In addition, management addressed the issue of the billing practice that could affect federal funding by seeking written clarification from a local agency.
Physician Group Billing Internal Audit
BlickenWolf was engaged by a physician group practice to analyze the
Medicare and Medicaid billing for the group. Internal audits performed
by the group had indicated potential improper billing of those agencies.
Through statistically valid sampling and medical record and billing
document review, we established a statistically valid rate of error
which allowed the group practice to voluntarily return a percentage
of its receipts and avoid a 100% review of all its billings. The
group updated its documentation guidelines and educated the physicians
involved to eliminate future errors.
