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The topic can be anything related to auditing - for example; auditing in a specific industry or p

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The topic can be anything related to auditing - for example; auditing in a specific industry or possible impact of SOX on industry, now that it has been around for a while.Your paper will be 7 to 10 pages long (not including title or reference pages) and will require a minimum of 3 professional references (information from your text cannot be counted as one of the references). Also, Wikipedia is not a professional reference and should not be used except for information that you will verify with other sources. The paper must be submitted using the APA writing style. If you are unsure how to use those styles, please locate a reference book or resource offered by Kaplan to become familiar with the style. The course topic (and outline to be submitted in a later unit) is required prior to submission of your final paper rough draft (meaning, get them in on time).Failure to do so will result in grade reductions. The project (all assignments inclusive) is counted to your grade as posted in the course syllabus. Deliverables required for this paper are as follows:Unit 6: Final paper due Reference the Individual Focus Paper Rubric in your Syllabus for grading information.

I am doing my paper on HealthCare auditing.  I have attached the rough draft, the instructions are above, and I also attached the outline and annotated biblography.  Please make the rough draft into a final paper to be submitted.  APA STYLE!

Running head: HEALTH CARE AUDITING Topic of Study: Health care Auditing


Jeffery Walburger


AC503 Advanced Auditing


September 26, 2016 HEALTH CARE AUDITING 2 Introduction


Standard health care is found on complete and accurate clinical validation in the health


care record. The preeminent way for one to improve his/her objective documentation and the


livelihood of his/her health-care organization is mainly through auditing of the medical records.


They are mandatory in determining areas which requires corrections and improvements.


The objective of an audit is to ensure there are effective and better delivery methods and


also upgrading the financial status of the medical contributor. The medical record audits largely


aims and assess methodology and identify the code selection that were determined by the


physician documentation. Once an audit reveals areas that has weakness, an auditor can present


the findings and also identify any opportunities for training in the health care organization.


Meaning of Medical Auditing?


Medical auditing involves conducting external or internal reviews of the coding accuracy,


procedures and policies so as to assure that one is running an effective, efficient and operation


free from liabilities (Jamtvedt, G., Young, J. M., Kristoffersen, D. T., O?Brien, M. A., & Oxman,


A. D. 2006).


Why perform medical auditing? HEALTH CARE AUDITING 3 Determining outliers prior to large payers discovering them in their respective claims


software which would result to them requesting an internal audit being carried out. It will protect against dishonest claims and also billing activity Medical claims will reveal if there is dissimilarity from expected averages due to


insufficient documentation, inappropriate coding, or the lost revenue. It will also help in identifying and correcting problem areas prior to government or


insurance payers summons inappropriate coding It also prevent governmental auditors such as the recovery audit contractors (RACs)


from investigating your health care organization It provide solutions for the under-coding, imperfect unbundling habits, and also code


overuse. To identify deficiencies on reimbursement and the accompanying opportunities for the


appropriate reimbursement. It also discontinue codes and procedures that are outdated and incorrect Become an Auditor


AAPC provides credentials for Certified Professional Medical Auditor which will help


physicians maximize billing and coding efficiency and standard of care through the auditing


process. The CPMA is of help to medical professional as it determine the key areas that has HEALTH CARE AUDITING 4 weakness in the medical practice. This will aid the medical persons to provide a detailed


recommendation to resolve them ("What Is Medical Auditing? - AAPC" 2016).


. Medical auditor, always focus on practice areas like: Compliance and regulations guidelines The Coding concepts The Scope and statistical sampling procedures Health care record auditing prowess and the abstraction ability Risk analysis and Quality assurance. Communication of findings and results Medical records reinforcing services that are offered Hire an External Auditor


AAPC has another audit services section, The AAPC Client Services. It dispenses a0


wide range of health care compliance, the audits of corporate integrity for both the outpatient


practices, government regulators, and health plans. So as to guarantee supported medical


requisite, the correct coding, and also acceptance with regulatory issues.




There are six types of health care auditing. They are ?.. HEALTH CARE AUDITING 5 Risk Adjustment and Medical Record Reviews (MRRs):


These audits are conducted to ensure that the medical record documentation substantiate claims


the data received, and also to ascertain if other unending conditions exist which may have been


omitted when submitting the claim. The obligation is on plans to validate that the patients faces


complications and the risks that are listed in the claims. If ascertained, the Medicare will help in


subsidizing the plans.


Medicare Advantage Risk Adjustment Data Validation (RADV)


CMS may demand health plans to conduct RADV audits at any time. The health plan always has


45 days in which they can send CMS ?one best medical record? that ascertain all submitted




Health Effectiveness Data & Information Set (HEDIS) Reviews


HEDIS audits basically reviews a section of the health plan group with a target on certain


measures, like diabetes monitoring. The facts and figures are then submitted to the Committee


for Quality Assurance where the quality report card is then generated by health plan. In addition,


the CMS make uses of HEDIS data in ranking the health plan performance. CMS has an


obligation to penalize those payers who decreases the quality scores. Providers always benefit


from the performance rankings of HEDIS, as they are used in gauging the standards of health


plans during the contract negotiations.


Diagnosis Related Group (DRG) Payment Integrity Reviews HEALTH CARE AUDITING 6 These audits check to ensure cases are appropriately sequenced and coded, and also the


billed information duplicate the record of the patient. It is fundamentally an inclusive review of


the hospital claims which have been proposed to health plans for payments.


Care and Quality Improvement Audits


Health plans do have specific illness and patient populations which are known as highrisk targets. The objective this audit for both health providers and health plans is to make use of


recommendations from case review so as to register subscribers into preventative care programs.


This is done prior to members? conditions advance and hospital admission is necessary. Both


payer and provider during the reviews look at the same cases. Their collaboration would results


to more appealing patient care and also will reduce healthcare costs.


Five-Star Program (Medicare Advantage)


This Program supplies NCQA and CMS with the techniques to assess the standards of the


health plans across the year. Those that indicate continuous upgrading in the patient experience,


reduced patient complaints, and also retained achievement of standard measures will receive a


more desirable performance score. Every year, the results can be constantly used by providers incase there is negotiations in the managed care contract ("6 Top Healthcare Audit Types" 2016).


Four Steps to Consider


The constant increase in the health plan audits reinforces the progressively serious need for


the hospitals to rationalize all the auditing management functions. Over centralization of audits, HEALTH CARE AUDITING 7 the streamlined communications to payers, audit education to management teams, and tracking


of all audit data are very critical keys in preparing for the coming year. Centralization motivates collaboration amid team members, save staff resources, dollars,


and time. Paying attention to improved communication between payers and providers will also cut


costs at the same time will help in mitigating the adversarial stress related and impact to


the commercial audits. Education between providers audit teams and payers is crucial as both parties tries to


comprehend requests, process records, meet the set deadlines and many other


responsibilities. Analysis of all records data that are sent to plans through audits is fundamental; the more


data obtained means the business intelligence (BI) will receive a greater support. In spite of which health plan the auditor sends a record request, providers should always


capture strong demographic data of each and every case reviewed. Particulars should be


mastered into the audit intelligence. The overall trend outcomes should then be used to guide the


process upgrading efforts, reduce future revenue uncertainty, and also notify managed care


contracting. The most salient data elements to be apprehended, tracked and observed through


audits are listed in below.


Elements to be captured during an Audit


1. Auditor review HEALTH CARE AUDITING



8 2. Dates of the service


3. Patient or service type


4. DRG codes


5. Original payment


6. Review reason References


Jamtvedt, G., Young, J. M., Kristoffersen, D. T., O?Brien, M. A., & Oxman, A. D. (2006). Audit


and feedback: effects on professional practice and health care outcomes. Cochrane Database


"6 Top Healthcare Audit Types". Healthcare Finance News. N.p., 2016. Web. 25 Sept. 2016. HEALTH CARE AUDITING


"What Is Medical Auditing? - AAPC". N.p., 2016. Web. 25 Sept. 2016. 9


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