CMS Training: Conduct Internal Healthcare Audit



Direct supervision of non-physician practitioners can actually mean a lot of different things, particularly when it comes to compliance and reimbursement for Incident to medical billing.We would encourage you to do a four phased process to conduct your own internal healthcare audit. Find out exactly where you are relative to all of this stuff concerning the provider based rule.


Phase 1:  It is simply sit down with a piece of paper and pencil, brand new legal pad. And write down every provider based thing that you have. Now you know, some of them maybe a little bit hidden. But try to write down everything you can. Do an inventory. You have some off campus. You have some on campus. Maybe some are inside the hospital. Who knows where they are?


Phase 2: Categorize them. Those that are inside the hospital or that you at least think are inside the hospital, we'll discuss that in a moment, those that are on campus but outside of the hospital and finally that are off campus.

Now, what you want to do with each of these is to look at each one of them a little bit differently because the healthcare guidelines requirements are a little bit different particularly from the physician supervision perspective.


Since some time, we thought that if you are on campus outside the hospital building but on campus that the direct physician supervision did not apply. So then for in hospital and on campus operations, we didn’t worry about that. While all of a sudden CMS  clarified that no that we were misinterpreting what they told us. And that yes, you do need to have direct physician supervision for on campus out of the hospital clinics.


Phase 3: Now, we've always had this requirement for off campus activities. So on phase three, go through analyze each one. Where are we? Who's doing what? Do we have any contracts?

Phase 4: Go through all of the rules for the provider based rule? Is it close enough? Is it financially integrated? Do we have common medical billings systems? All of these other things go through all of this. And then of course take appropriate action as you need to.

There's no magic here, guys. This is just a four-phased process. And we have used this web hospitals to analyze and figure out where they are. One of the hardest things for you to see is going to be inside the hospital where you're doing what we call provider based clinic goal. You might as well take this phrase down, provider based clinic goal, CAL on the end of the clinical.

And these are just adhoc type services that you file a UB04 as per CMS rules. but they could be considered to be just clinic services. Now, you're not in a formal clinic. You're just doing outpatient services inside the hospital. Those are oftentimes the hardest to recognize.

For instance, if you don’t already have a pain management clinic, you may have some anesthesiologist that are seeing patients in an outpatient area. They're assessing the patients. And they're doing a pain injections.

Well, those are provider based clinic goal services. And yes, you need to be filing a UB04. And the anesthesiologist will file the 1500. So those are kind of hard to see.

Healthcare Training Tip:  First of all, inventory, identify everything. And get out. You know, everything licensed? Is it properly accredited? Do we have an under the accreditation process? Do we have the certifications? Did the organizational chart show that there is direct supervision out to this provider based bank just as it would be if it were inside the hospital?


Medical staff bylaws, how do they apply? Now, here, you can have some interesting situations because this provider based clinic might be 20 miles away. And the physicians out of the provider based clinic may be more closely associated to another hospital.


Are these physicians on your medical staff? They certainly should be if this is going to be your provider based clinic. And then accounting management, campus match, all of those other stuff, just inventory and try to get any information you can about the provider based thing you're dealing with.


Phase two categorized in hospital versus on campus but outside the hospital and then off campus. This may not be as easy as anticipated. You might be surprised when you try to do this.


Phase three, assess, use the four prongs, the obligations, the prohibitions, et cetera. And then of course develop exit plans. Now, today, in developing action plans, it's a little tough.

What are the criteria?

Now, for the most part, you're not going to have any trouble with these criteria. Although there are some that are troublesome. For instance, let's say that you have a provider based clinic. It's off campus. It's 20 miles down the road. They have their own medical record keeping system to ensure healthcare compliance. They have their own patient record out at the clinic.


One of the criterion is that the medical record system needs to be integrated. In other words, if this language is really a part of a hospital, then the medical records at that clinic really need to be integrated into the main hospital medical recordkeeping system.


Now, this can be a challenge because we certainly aren't going to be hauling charge back for it. What we have found is that if we have found is that if we cross index them, if we cross reference them, that seems to be good enough.


Our expert mentioned in a CMS  conference that if you have a patient coming into the hospital and you pull up their medical record to the hospital, there would be pointer pointing to the clinic of the fact that there's a record out there as well and vice versa. So, cross referencing seems to be enough. But you can get into some very - well, some very interesting situations, let's put it that way.


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