Preparing for a Healthcare Coding and Compliance Audit

When a surveyor walks into your facility for an audit, there’s usually a sense of anxiety and tension, even when you know you’re prepared. An audit is like a final exam. If you’ve been preparing all along, you’re much calmer, but if you’ve waited until the last minute, then you’re cramming and overwhelmed and scrambling to make sure you’re ready.

Being prepared for a healthcare coding and compliance audit protects your healthcare organization from significant risks, such as fines, reimbursement issues, and potential loss of patient trust. Regular audits from regulatory bodies such as the Centers for Medicare & Medicaid Services (CMS) or the Health Resources and Services Administration (HRSA) are a necessary part of operating in the healthcare industry.

With proactive preparation, you can minimize stress and improve audit outcomes. This article will walk you through the steps so that your organization is healthcare coding and compliance audit-ready.

Understand the Scope of the Healthcare Coding and Compliance Audit

Healthcare coding and compliance audits evaluate adherence to laws, regulations, and internal policies. Some are pre-scheduled, while others are unannounced — like a pop quiz.

Auditors have a checklist they use to evaluate your organization’s compliance. In addition to reviewing records and documents, they’ll walk around observing and asking staff questions — this is when your survey-readiness will really show. The surveyor or auditor will give you feedback and findings, some of which may require a healthcare plan of correction.

These are some of the regulatory inspections your healthcare organization may undergo:

Occupational Health & Safety Organization (OSHA): ensures employees are protected from hazards that compromise their safety and health.
Office of Inspector General (OIG): conducts audits to identify and prevent fraud, waste, and abuse in healthcare programs.
Office of Civil Rights (OCR): investigates compliance with HIPAA, ensuring patient privacy and data security.
Centers for Medicare & Medicaid Services (CMS): most focused on coding efforts, scrutinizing accuracy in claims and billing to prevent improper payments and keeping compliant with coding guidelines.

Aligning your processes with these requirements well in advance of a healthcare coding and compliance audit establishes that your organization operates efficiently and stays compliant. Regular internal reviews and updates to procedures help mitigate risks and avoid surprises during audits.

Conduct an Internal Healthcare Coding and Compliance Pre-Audit

Conducting an internal healthcare compliance audit is a cost-effective way to make sure your organization adheres to legal and regulatory standards while proactively addressing risks. Here’s a simplified approach:

Risk Assessment

Pinpoint vulnerable areas for targeted attention to focus on high-risk aspects.

Planning

Define the scope and objectives of the audit, identify audit areas, and establish a timeline.

Gathering Information

Collect relevant documentation, policies, procedures, and other materials necessary for the audit.

Assessing Compliance

Review the collected information to evaluate compliance with legal and regulatory requirements.

Identifying Gaps

Identify any areas of non-compliance, weaknesses, or opportunities for improvement.

Implementing Corrective Measures

Develop and execute action plans to rectify non-compliance issues and strengthen compliance protocols.

Monitoring and Follow-up

Regularly monitor compliance and assess the effectiveness of implemented corrective measures. Maintain detailed records of compliance efforts, including audit findings, corrective actions, and monitoring activities.

By addressing findings from a pre-audit, your organization can resolve issues, reduce risks, and present a stronger case for compliance during official audits.

Ensure Staff Awareness of Compliance and Coding Requirements

Maintaining awareness of the requirements and providing consistent training helps to reduce the likelihood of audit findings. However, high healthcare staff turnover can make it difficult to keep all employees up-to-speed.

Use your healthcare compliance training plan to provide a regular cadence of education, focused on regulatory topics and common issues in your care setting. Be sure that you can demonstrate to auditors that all staff have completed training, as that will show the proactive measures you’re taking to prevent fraud.

All employees are required to complete healthcare fraud, waste, and abuse training annually. This helps staff identify and avoid common types of fraud, such as: double billing, upcoding, phantom billing, and unbundling.

Medical coding is inherently complex, and mistakes can occur even among seasoned coders. While audits are effective for uncovering and addressing these errors, the risk of inaccuracies remains an ongoing challenge.

Be Prepared With Organized Documentation and Records

Accurate, complete, and timely documentation is the backbone of a successful audit. Missing or incomplete records can raise red flags, leading to extended healthcare coding and compliance audit timelines and potential penalties.

Organize all relevant documentation — including policies, procedures, and training records — in advance of an audit. When a surveyor walks in, they will select random medical records and coding documentation to verify adherence with established coding standards. If you can quickly show these records, it will be a much smoother process.

Surveyors will also request to see specific policies and training completed by an employee chosen at random. Customizing real-time reports for your organization’s auditors will make it simple to provide this documentation.

For an organization that is using inefficient or mediocre workflows, it will be much more difficult to get everything in check, especially for external inspections that can occur without notice.

Use Technology to Simplify Healthcare Coding and Compliance Audit Preparation

All-in-one healthcare compliance software brings all critical tasks into one platform. When incident reports are right alongside compliance training, it is simple for employees to complete and for administrators to share with surveyors.

Here are some ways that healthcare compliance software helps you stay audit-ready:

Comprehensive Policy & Document Management

Centralized storage and version control for policies, procedures, and safety plans put required information at your fingertips when the auditor walks in.

Customizable Reporting

Customizing your compliance reports with the information each auditor needs will save you time and stress during a healthcare coding and compliance audit. Plus, you’ll know at-a-glance if there are gaps or non-compliance issues.

Incident Reporting & Escalation Management

Online incident management helps identify potential issues before they become a problem to effectively reduce your organization’s risk. It provides clear evidence of compliance with regulatory requirements such as timely reporting and resolution of incidents, simplifying the audit process.

Training Management

A healthcare learning management system keeps employees up-to-date on training with automated completion reminders and annual reassignment of courses.

Compliance software offers these benefits and more, streamlining the preparation process so your organization can save time.

Develop a Healthcare Coding and Compliance Audit Response Plan

Even with the best preparation, audit findings may arise. Having a solid corrective plan ensures you can resolve these discoveries quickly and effectively.

Here are some steps to take:

Find Root Cause & Implement Changes

Based on the feedback received from the audit, the first thing to do is understand how to fix these deficiencies (some leaders will conduct a root-cause analysis) and implement corrective action.

Provide Training & Education

Assign training for the specific deficiency so that the right people are getting the right education. Using a healthcare learning management system, you can assign refresher training to all relevant employees with just one click, and completion is automatically tracked so you can provide proof if needed.

Monitor & Adjust

Update coding procedures, provide training, and implement new technology to adjust to the findings of your corrective action plan.

Be Survey-Ready With MedTrainer

If you want to successfully navigate healthcare coding and compliance audits, your organization should prepare proactively. By focusing on organization, training, and leveraging technology, your organization can reduce risks, streamline compliance processes, and strengthen overall operations.

Healthcare compliance software, such as MedTrainer, simplifies these efforts, helping you stay ahead of regulatory requirements. Keep your team ready for any audit and maintain confidence in your organization’s compliance practices.

Find out how MedTrainer can help you prepare for a healthcare coding and compliance audit.

How To Prepare for a Healthcare Coding and Compliance Audit