Sample Board Report 2: Quarterly Report

By Greg Radinsky, JD, MBA, CHC, CCEP

Office of Corporate Compliance Draft Quarterly Report: [X] Quarter [YEAR]

[YEAR] Completed Audits

Below is a listing of the audits that were completed by the Office of Corporate Compliance in the [X] Quarter of [YEAR].

The following slides provide a detailed summary of the audit findings for each audit. Additional information or a copy of the final audit reports are available upon request.


[YEAR] Audits
Place-of-Service Errors in Ambulatory Surgery Units
Ambulatory Surgery Unit Coding/Billing
Physician Impact of Opting Out of Medicare
Ambulatory Surgery Unit Coding/Billing
Ambulatory Surgery Unit Coding/Billing
Ambulatory Surgery Unit Coding/Billing
Syncope Medicare Severity Diagnosis-Related Groups (MS-DRG)
Physician Review
Ambulatory Surgery Unit Coding/Billing
Radiology
Pulmonary Edema and Respiratory Failure MS-DRGs
Ambulatory Surgery Unit Coding/Billing
Ambulatory Surgery Unit Coding/Billing

[YEAR] Final Compliance Data Mining Audits


Final Audit	Overpayments	Findings	Corrective Action
XXXXX	No overpayments	No material findings	N/A
XXXXXXX	1 underpayment (~$202.25)	1 or 25% of the cases reviewed were assigned the incorrect MS-DRG 1 or 25% of the cases reviewed were assigned an incorrect ICD-9-CM code	Appropriate staff has been educated, and a refund has been processed

[YEAR] Final Compliance Facility Audits


Final Audit	Overpayments	Findings	Corrective Action
XXXXX	No overpayments	No material findings	N/A
XXXXXXX	1 underpayment (~$202.25)	1 or 25% of the cases reviewed were assigned the incorrect MS-DRG	Appropriate staff has been educated, and a refund has been processed

[YEAR] Final Compliance Professional Fee Audits


Final Audit	Overpayments	Findings	Corrective Action
XXXXX	2 Overpayments (~$200.00)	E/M levels Missing documentation	Appropriate staff has been educated, and a refund has been processed
XXXXX	No overpayments	No material findings	N/A


Total overpayments this quarter	~$200.00

[X] Quarter [YEAR] Compliance Helpline


Issue	Cases	Percentage of Total
Coding, Billing, and Contracts	5	2.1%
Conflicts of Interest	2	0.8%
HIPAA/Confidentiality	75	31.5%
Human Resources	113	47.5%
Other	10	4.2%
Patient Care/Quality	20	8.4%
Question/Violation of Policy	13	5.5%
Theft	0	0
Total	238

The compliance helpline is an avenue by which individuals or interested parties may report any issue or question associated with any of the hospital’s policies, conduct, practices, or procedures believed by the employee to be a potential violation of criminal, civil, or administrative law, or any unethical conduct. Inquiries can be made via the helpline 24 hours a day, seven days a week. Individuals are encouraged to report any problem or concern either anonymously or in confidence via the helpline as they deem appropriate.

To date, the number of internal and helpline cases received during [X] quarter of [YEAR], was 238.

The grid describes the general categories of reports received during [X] quarter. The largest number of issues arose in the human resources category, followed by HIPAA. The human resource calls are referred to that department for investigation.

The HIPAA calls resulted in 40 investigations that have taken place since [Month] 1, and approximately 100 interviews that were conducted related to inappropriate access to patient information. All identified issues were handled appropriately.

Any questions related to these issues should be directed to your site-specific compliance director.

[X] Quarter HIPAA Breaches

Below is a listing of the HIPAA breaches that were reviewed by the Office of Corporate Compliance in [X] Quarter of [YEAR].


Allegation	Facility	Status
Misdirected fax	XYZ	Investigated. Unauthorized disclosure and breach. Will notify U.S. Department of Health & Human Services at year-end.
Employee accessed electronic medical record of patient who is a relative without authorization	XYZ	Investigated. Unauthorized access, unauthorized disclosure, and breach. Will notify U.S. Department of Health & Human Services at year-end.

[X] Quarter Completed HIPAA Initiatives


Initiative	Facility	Status
Breach detection software used to systematically identify users who are engaging in patient access patterns that are indicative of snooping, identity theft, or other risky behaviors	XYZ	In progress