Internal Audit and Compliance Reporting Summary March 14, 2019 1
Compliance Long Range Plan One of the core requirements from the Compliance Resource Group (CRG) was that Compliance should develop a 3-5 year strategic plan to model the evolution of the Compliance Program and move from reactionary to “optimized”. A draft of the long term plan has been provided for the committee’s review. The plan addresses: • AHS Strategic Plan (summarized) • The objectives of the Internal Audit and Compliance Programs • The 7 Elements of a Compliance Program and how we meet them • Current Staff Assessment • Future Organization Structure • Strategies to Accomplish our Objectives 2
Compliance Long Range Plan The long range plan identifies that Internal Audit and Compliance has a small but experienced staff. The Compliance department has been in existence for 3 ½ years and while the program foundation has been implemented, there is a continued need to develop policies and training programs to educate management and the workforce on the various aspects of compliance. Education and experience gaps such as Long Term Care, Managed Care and Behavioral Health have been identified and plans are in place to train staff members in these aspects of healthcare. With the implementation of EPIC, budget dollars will be tight and staff increases will be difficult to justify. Internal Audit and Compliance will continue to drive for improvement with available resources, but may remain in a reactionary mode for some time. 3
PRIME Year 3 BACKGROUND: The Public Hospital Redesign and Incentives in Medi-Cal project (PRIME) is a continuation of the DSRIP initiative. AHS is currently in year 3 of this 5 year project and was eligible for $32.2M in incentive payments based on meeting certain reporting metrics. There were a total of 56 metrics selected for reporting in 9 categories. SCOPE OF REVIEW: Internal Audit testing was designed to determine that the project reporting accurately addresses key deliverables and that adequate documentation was maintained to support reported results. RESULTS OF REVIEW: Based on the analysis performed, the PRIME group successfully met 54 of the 56 metrics and over-performed in certain metrics to earn $32.1M of the $32.2M available incentives. 4
PRIME FINDINGS/RECOMMENDATIONS: The project team centralized all project support files to resolve the documentation issue identified in the previous report. This year’s audit did not identify any material issues. 5
LAB CHARGES BACKGROUND: The Lab Department currently uses Novius (a lab information system) to capture patient lab procedures that are then uploaded into Soarian Financials for billing purposes. As part of the EPIC conversion in September 2019, Novius will be replaced with Beaker, an EPIC lab application. Included in Novius is a list of lab procedures to capture charges as procedures are performed for patients. If Soarian Financials and Novius are not in-sync, AHS is unable to bill for services rendered. SCOPE OF REVIEW: The Lab Department is currently working with the Revenue Integrity Group to go through a comprehensive review and consolidation of the Lab CDMs to verify the completeness of the procedure and charge codes in preparation for the EPIC conversion and the roll out of the Beaker Lab application. Internal Audit performed an independent reconciliation of all currently used procedure codes between Novius and Soarian Financials for the Highland and Fairmont labs. 6
LAB CHARGES RESULTS OF REVIEW: Based on the analysis performed, there appeared to be an adequate process in place to capture lab charges for services provided to patients. Internal Audit identified several charges that were not being captured that amounted to a few hundred dollars a month. Corrections are being made as part of the Epic conversion. FINDINGS/RECOMMENDATIONS: Lab management should implement a recurring procedure code reconciliation between Beaker and the Master CDM, post EPIC implementation, to verify that all lab charges are setup in Beaker and have a valid charge code and price assigned to them. Management Response: Management agrees with the finding and will implement procedures post Epic implementation to reconcile charge codes. This will be completed by October 31, 2019. 7
HIPAA Walkthrough Assessments Completed the Following: Fairmont Hospital/SNF San Leandro Hospital John George Psychiatric Pavilion Walkthrough Assessments have been completed at all system sites and documented in 10 separate audit reports. Additional assessments will be conducted in FY2020. 8
HIPAA Walkthrough Assessments Background The assessments were designed to: • Verify compliance with HIPAA Privacy requirements in several key areas; • Identify opportunities for improvement in compliance with HIPAA Privacy regulations; and • Identify areas where additional HIPAA Privacy training may be needed. The scope of the reviews included: Printing Exchange of PHI Faxing/Copying E-mail Storage/Disposal Mail Computers Notice of Privacy Practices Telephones Personnel Issues 9
HIPAA Walkthrough Assessments Common Themes/Improvement Opportunities PHI on Shared Printers Fax Machines not Pre-Programmed Unsecured Filing in Public Area Notice of Privacy Practices not Posted Confidentiality Statements on Email Lack of Privacy Screens on Public Facing Computers 10
340B Highland Hospital 340B is a significant level of focus in FY2019. The 340B Oversight Committee routinely monitored transactions for compliant billing; however, issues were identified in the audit process in February 2018. Past periods were reviewed by Internal Audit to determine the impact of the issues. Audit results indicated increasing error rates for UD Modifiers. 20% 40% 94% 100% 2.5% 1.1% 0% 4/17 7/17 9/1717 2/18 4/18 8/18 12/18 Errors Errors Errors Errors Errors Errors Errors As shown in the results above, system issues have been corrected and we are moving closer to a 0% error rate. Manual processes are also being addressed to improve the accuracy of 340B processing. January 2019 Audit in Process 11
340B Alameda Hospital Audit of the last 30 Days activity showed a 69% error rate. UD Modifiers were confirmed to be in the Charge Master (CDM). A mapping issue was identified and corrected in the Meditech system. Additional audits are being conducted to confirm the fix. 12
Other Reports FY 2019 Annual Plan – On Time. Compliance Program Assessment – Completed 29 of 36 recommendations. Delays in finalizing the Compliance Long Range Plan and the Code of Conduct have delayed completion of 5 issues. Compliance Issues – High volume of Reported Issues, Significant Progress closing issues, but still a Significant Backlog of Pending Issues. Continuing to address Backlog. Follow-up on outstanding findings continues. There are 43 open issues currently, compared with 61 open issues from the last report. 15 open issues are related to HIPAA Walkthrough Assessments. 13
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