Our audit program is in place to monitor compliance with applicable laws and UBMD policies. The focus of the program is to assess the accuracy of documentation and coding of UBMD providers, while the objectives are:
Routine prospective chart review (Periodic Audit) is required for each Practice Plan to assess compliance with the established standards of practice and billing guidelines. Charts will be audited without regard to payer type.
There are several types of audits that may be performed, including:
Designed to identify deficiencies and inconsistencies in the documentation and billing process in order to develop strategies for improvement, including educational sessions. The internal auditor for each Practice Plan is responsible for annually reviewing the lesser of 2% of each provider’s submitted claims, or 10 claims, unless a more stringent requirement is otherwise specified in the individual Practice Plan compliance policies.
If a provider’s charts are found to be less than 85% compliant, the internal auditor will conduct an individual educational session and perform a follow-up audit within six weeks to evaluate the effectiveness of the education. The provider will then receive a second, problem-focused, audit. Failure to improve compliance percentages may result in additional corrective action being taken.
For the purposes of periodic audits, a minimum of ten (10) records will be reviewed annually per full-time provider. Each Practice Plan is responsible for reporting internal audit results to the UBMD Director of Audit & Education once each year, with a minimum of ten (10) records per provider, on a form acceptable by the UBMD Director of Audit & Education (links to the forms are below). Audit results will contain information such as number of encounters reviewed, the number of compliant and noncompliant records, review codes for noncompliance, and follow-up activities for tracking and educational purposes. A plan of correction should be reported for all deficiencies identified.
Additional records may be reviewed at the discretion of the UBMD Compliance Officer.
Periodic and follow-up audits will be conducted by auditors retained by the individual practice plans. In the event a Practice Plan does not retain an auditor, or if the auditor designated by the Practice Plan fails to review a minimum of ten (10) records per year per provider, then the Compliance Officer may choose to hire an auditor to fulfill such obligation, at the expense of the Practice Plan in question.
Periodic audits are independent and impartial chart reviews. They will remain separate from the coding function within the Practice Plan. Auditors must not be the same person who codes the medical records.
Conducted by an internal auditor, UBMD’s Compliance Officer, or his/her designee in response to issues or concerns that might arise within a Practice Plan either by an employee or an outside source. The auditor will consult with the Compliance Officer or his/her designee and the Practice Plan President prior to conducting an unscheduled audit.
May be conducted any time an outside agency such as the U.S. Attorney’s Office, U.S. Department of Justice or the New York State Attorney General’s Office initiates an investigation of a UBMD provider or Practice Plan. These audits are intended to provide the UBMD Compliance Officer with information that may be helpful in defending or settling any charges that may arise from the outside investigation.
Audits may be conducted at the request of the Compliance Officer at any time to ensure compliance with third party billing requirements and/or applicable fraud and abuse laws.