To ensure consistency and efficiency in the audits at WellSpan Health in York, Pennsylvania, Compliance Audit Coordinator Frank Mesaros documented its audit process in a manual and then put it in an electronic form when everyone scattered because of COVID-19 (see story, p. 1).[1] Here’s one of the documents from the audit manual. Contact Mesaros at fmesaros@wellspan.org.
|
STEP 1: RESEARCH AUDIT TOPIC |
DATE COMPLETED |
COMMENTS/WORK PLAN REFERENCE |
|---|---|---|
|
Identify risks from previous internal/external audits or other risk analyses (such as bell curve analysis). | ||
|
Review source of risk documents. | ||
|
Identify department contacts. | ||
|
STEP 2: NOTIFY MANAGEMENT OF THE AUDIT IN PERSON OR VIA CALL |
DATE COMPLETED |
COMMENTS/WP REF |
|
Send pre-audit survey to manager. | ||
|
Discuss any issues/concerns with manager. | ||
|
Schedule date to begin field work. | ||
|
Address any deficiencies noted in the pre-audit survey (such as lack of a hotline poster). | ||
|
STEP 3: PERFORM AN OVERVIEW OF DEPARTMENT FUNCTIONS, IF APPLICABLE |
DATE COMPLETED |
COMMENTS/WP REF |
|
Request relevant policies and procedures. | ||
|
STEP 4: PREPARE PAPER/ELECTRONIC AUDIT FOLDER, INCLUDING WORKPAPER INDEX |
DATE COMPLETED |
COMMENTS/WP REF |
|
STEP 5: DETERMINE SCOPE AND SAMPLE SIZE TO REVIEW |
DATE COMPLETED |
COMMENTS/WP REF |
|
Obtain population of claims for sample selection. | ||
|
Select sample (describe population and document how sample was selected). | ||
|
STEP 6: DETERMINE AUDIT CRITERIA (ATTRIBUTES TO BE TESTED) AND DEVELOP AUDIT PROGRAM/SPREADSHEET |
DATE COMPLETED |
COMMENTS/WP REF |
|
STEP 7: REQUEST AND VIEW RECORDS, BILLING, AND CLAIMS |
DATE COMPLETED |
COMMENTS/WP REF |
|
Record findings in spreadsheet. | ||
|
Review findings for trends; group findings into categories. | ||
|
Document last date of field work (this will be the report date). | ||
|
STEP 8: HOLD AN EXIT CONFERENCE TO NOTIFY DEPARTMENT MANAGER OF PRELIMINARY FINDINGS |
DATE COMPLETED |
COMMENTS/WP REF |
|
Allow for department to provide additional supporting documentation, if available. | ||
|
Revise spreadsheet, if applicable. | ||
|
STEP 9: WRITE DRAFT REPORT (REFERENCE AUDIT REPORT POLICY) |
DATE COMPLETED |
COMMENTS/WP REF |
|
Include audit number from work plan in report title. | ||
|
Send draft report to audit coordinator for review. | ||
|
After coordinator approves, send draft to director for review and approval. | ||
|
STEP 10: SEND DRAFT REPORT AND “GUIDANCE FOR MANAGEMENT COMMENTS” TO DEPARTMENT MANAGER |
DATE COMPLETED |
COMMENTS/WP REF |
|
Allow two weeks for management to respond (diary your calendar). | ||
|
Review management response for sufficiency. | ||
|
If responses are sufficient, continue to next step. Else, work with manager to address insufficient or incomplete responses. | ||
|
STEP 11: WRITE FINAL REPORT |
DATE COMPLETED |
COMMENTS/WP REF |
|
Include “Compliance Response to Management” comments, if appropriate. | ||
|
Send report to coordinator for review and approval. | ||
|
Send report to director for review and approval. | ||
|
Enter link to final approved report. |
LINK: | |
|
STEP 12: RELEASE FINAL REPORT, ONCE APPROVED |
DATE COMPLETED |
COMMENTS/WP REF |
|
Send paper copies to designated managers, VP, president of entity, counsel, etc. |
Ensures reports are not easily forwarded on to anyone outside WellSpan Makes sure the reports do not get lost in email of our senior leaders | |
|
Ensure a copy of final report is included in audit work papers. | ||
|
Send a copy to coordinator for inclusion in the audit binder. | ||
|
Upload to portal. | ||
|
Send an email copy of the completed report to compliance department team members that conduct hospital or defense audits. | ||
|
Prepare audit slides and save to report folder. | ||
|
STEP 13: SEND POST-AUDIT SURVEY TO MANAGER WITH INSTRUCTIONS TO RETURN TO DIRECTOR |
DATE COMPLETED |
COMMENTS/WP REF |
|
STEP 14: DETERMINE POST-AUDIT CORRECTIVE ACTIONS TO MONITOR (AUDIT COMMENT FOLLOW-UP) |
DATE COMPLETED |
COMMENTS/WP REF |
|
Perform testing to ensure corrective actions have been put into place (60 days from report date). | ||
|
Diary your calendar for this follow-up. | ||
|
STEP 15: DETERMINE IF/WHEN RE-AUDIT IS REQUIRED. DISCUSS WITH AUDIT COORDINATOR |
DATE COMPLETED |
COMMENTS/WP REF |
|
Diary your calendar for the follow-up audit. | ||
|
STEP 16: INCLUDE A COPY OF THIS CHECKLIST IN THE AUDIT WORK PAPERS |
DATE COMPLETED |
COMMENTS/WP REF |
|
STEP 17 |
DATE COMPLETED |
COMMENTS/WP REF |
|
On a scale of 1-5, with 5 being the best, rate the department on how knowledgeable you feel the staff is on compliance. |
1 2 3 4 5 |
