Auditing and Monitoring

Approval/Effective Date: 2/9/2009

Last Reviewed: 4/27/2015

Policy: The University of Washington School of Dentistry will conduct audits to monitor the effectiveness of the Compliance Program. Audits will include reviews to verify Compliance Program policies are being followed, as well as reviews of School of Dentistry documentation, billing and coding to verify compliant billing practices.

The School of Dentistry will devote such resources as are reasonably necessary to ensure that the audits are (1) adequately staffed; (2) performed by persons with appropriate knowledge and experience to conduct the audits; (3) utilizing tools and protocols which are periodically updated to reflect changes in applicable laws and regulations. Monitoring activities will include compliance audits and program reviews:

Compliance Audits; The University of Washington School of Dentistry will conduct periodic compliance audits by auditors who have expertise in federal and state healthcare statutes, regulations, and Federal health care program requirements.

Program Reviews; The University of Washington School of Dentistry will annually assess whether or not Compliance Program elements have been satisfied.

Purpose: The purpose of this policy is to ensure the effectiveness of the Compliance Program by establishing audit procedures.

Procedures:

1. The Compliance Director is responsible for maintaining the comprehensive Compliance Audit Plan for the School of Dentistry, to include audits/reviews conducted by the Compliance Director or designee, outside consultants and individual departments. The Compliance Director will oversee audits conducted by Departments.

2. The Compliance Director will verify completion of audits/reviews on the Compliance Audit Plan and any corrective action measures arising from them.

3. Compliance staff will compile quarterly reports to include, but not limited to, summary of errors, error rates, review outcomes and departmental/clinic statistics. Auditors/reviewers and the Compliance Director will meet with the appropriate department/clinic management (and others as requested) to review and discuss the departmental/clinic quarterly results prior to finalizing the summary report. In advance of the meeting, a copy of the results will be distributed to the attendees. The purpose of the meeting is twofold:

Give the department/clinic the opportunity to provide explanation or additional documentation to clarify any concerns that have been identified in the audit.

Create a departmental corrective action plan to address any adverse findings. This plan will identify the deliverables and the due date and individual responsible for each. If the plan requires additional time to produce, the meeting participants will agree on a due date for the department to submit the corrective action plan to the Compliance Director.

4. The Compliance Director will distribute the final quarterly departmental/clinic summary reports, including any necessary corrective action plan(s). At a minimum, the final summary reports will be sent to the following individuals:

  • Manager of the department/clinic audited/reviewed
  • Department administrator
  • Department chair
  • Associate and Assistant Deans of Clinical Services

5. The Compliance Director will monitor for completion of the departmental corrective action plan. Once the corrective action plan is completed, the Compliance Director or designee will perform a follow-up audit to ensure the effectiveness of actions taken.

6. In all cases, Departments will initiate resolution actions within 14 days of receiving adverse finding information.

7. The Compliance Director will maintain a tracking system wherein corrective action plans and follow-up verification are monitored for completion.

8. The Compliance Director will routinely report to the Compliance and Training Committee on the results of audits and the status of corrective actions.