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Conducting a Gap Analysis / Mock Audit: An Essential Compliance Tool for Your Practice.

Health Care Providers Should Conduct a GAP Analysis / Mock Audit of Their Claims. (November 15, 2011): Understandably, health care providers have grown weary of government audits, malpractice issues, peer reviews and private payor assessments.  In an effort to reduce their potential liability, many providers are now regularly utilizing Gap Analyses Mock Audits to test their preparedness for audit.  In doing so, they have been able to identify and correct potential problems before they result in more serious problems.  The purpose of this brief article is to discuss the process of conducting a preliminary or mock audit of your medical records, documentation, coding and / or billing practices so that remedial measures can be taken if deficits are identified.

 

I.     “How Much is Enough” When You Are Implementing an Effective Compliance Program?

Drafting and implementing an effective compliance plan, conducting a GAP Analysis and training your staff on compliance issues are essential steps toward the peace of mind compliance can bring. But the question remains — how do you know when you’ve done enough?

In the end, the answer is that you can never do enough to completely eliminate all the risks, but you can minimize those risks and limit your possible exposure through the implementation of, and adherance to, an effective compliance plan. Mock audits can be used as a way of “testing” your compliance initiatives.

II.     How is a Gap Analysis or Mock Audit Conducted?

In a mock audit, an individual or team acts as a government agency or contractor (such as a ZPIC, RAC or MAC), and visits the practice or facility unannounced.  The mock auditor would then pull a random set of records to conduct a documentation analysis (often including both medical records and business arrangement records). Once the records are pulled, an analysis of the relevant findings is completed. These results would then be discussed with practice management so that the relevant strengths and potential areas of concern can be addressed.

III.     What is the Goal of a Gap Analysis or Mock Audit?

The goal is to test both your staff’s reaction to the exercise, as well as their understanding of what may be expected in a real audit. Moreover, the documentation analysis may be invaluable, revealing weak points in the facility’s documentation activities.  You may also learn that some of your forms (such as your Encounter Form) are defective. Finally, you will likely learn more about the various training needs of your staff.  A mock audit may also ferret out problems that management didn’t know or didn’t realize existed.  You may learn that a business arrangement or relationship is questionable or that your staff has been relying on the wrong LCD or other guidance when documenting and billing for services.  Fundamental problems such as illegibility and missing signatures may also be identified.  In any event, the results of a mock audit can be used by the practice to bolster and support its compliance initiatives.

IV.     Sound Like a Good Idea?  So, what’s the First Step?

Sound like a good idea?  Before you embark on a mock audit, you should contact your attorney and discuss any privilege issues which may exist.  As a final point, keep in mind that should you identify an overpayment, it must be returned to the government within 60 days of identification and reconciliation.  Otherwise, the overpayment could constitute a violation of the False Claims Act.

robert_w_lile-150x150Robert W. Liles, Esq., serves as Managing Partner at Liles Parker, Attorneys & Counselors at Law.  Robert and other attorneys at Liles Parker are experienced at conducting “gap analyses” and “mock audits” of physician practices, home health agencies, hospice agencies and other non-hospital provider entities.  Should you have any questions about conducting a mock audit or would like to learn more about having Liles Parker attorneys assist your practice, please call us for a free consultation.  Robert can be reached at:  1 (800) 475-1906.

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