Audit Subject |
Purpose |
Scope |
Lead Person Responsible |
Department |
Projected Timing |
---|---|---|---|---|---|
Medical Necessity of Diagnostic CT and MRI |
To determine compliance with CMS guidelines including physician order, place of service, prior authorization, documentation requirements, specificity of exam, etc. |
Small physician practice may be 100% prospective review with large organizations at 10% prospective review |
[name] |
Compliance |
1st Quarter |
Exclusion Review of Employees, Contractors, Vendors |
To validate that exclusion review is being performed at hire and every 30 days on physicians, employees, contractors, vendors |
100% review of exclusion monitoring reports for past 12 months; validate a random sample of exclusion reviews reported |
[name] |
Compliance |
1st Quarter |
Evaluation & Management Documentation & Coding |
To determine compliance with E/M coding guidelines. |
Retrospective review of medical records with DOS January 1-March 31, 20xx Statistically valid random sample |
[name] |
Compliance |
2nd Quarter |
Physician Contract Review |
To assess compliance with Stark and/or Anti-Kickback Statute; to assess compliance with terms of contract; to review physician compensation |
Small physician practice – all contracts. Large organization – random sample |
[name] |
Compliance and Legal |
3rd Quarter |
HIPAA Privacy & Security Measures Implemented for Telehealth |
To determine if provider is using approved telehealth platform; to determine whether a BAA exists; to determine if informed consent for telemedicine was obtained from the patient; to determine whether a system for monitoring communications containing ePHI have been implemented; to determine whether only authorized users have access to ePHI |
Statistically valid random sample |
[name] |
Privacy and Compliance |
4th Quarter |
Resource: Sample Compliance Program Audit Plan
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