CurrenthometownhealthprovidersPolicy Hometown.HCP.007

Auditing and Monitoring

Customize your policy alerts

Sign up for hometownhealthproviders Policy Hometown.HCP.007 alerts

Get alerted when Policy Hometown.HCP.007 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Establishes Hometown Health's auditing and monitoring program for compliance with federal, state and internal requirements, applying to Hometown Health staff, leadership, board, FDRs, and network providers.

Policy Summary

Payerhometownhealthproviders

PolicyAuditing and Monitoring

Policy CodePolicy Hometown.HCP.007

Change TypeNo material changes

Effective DateMay 1, 2018

Last ReviewAug 19, 2016

Next Review DateMay 1, 2020

Key ActionCompliance policies apply to staff, board, FDRs and network providers; FDR oversight included in auditing activities.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

annualeffectiveness assessment frequency

fiscal yearwork plan schedule coverage

includes FDRsoversight scope

remote/onsite/unannouncedaudit types

Auditing and Monitoring Program Criteria

Auditing and monitoring program requirements and processes

Develop organizational risk assessment to identify and prioritize risks

ALL of the following

Work plan includes audits to be completed, audit schedules, announced or unannounced audits, internal or external audit, audit methodology, required resources, type of audit (remote desktop or onsite), responsible person, final audit report due date, and follow up and corrective action plans from findings.

Work plan must include a process for responding to audit and monitoring results and for conducting follow-up reviews of areas found to be non-compliant to determine if corrective actions have addressed the root cause

Corrective action and follow-up is led and/or overseen by the Compliance Officer; findings may be self-reported to the applicable regulatory entity

Audit types include

Remote desktop audits
Onsite audits
Unannounced audits or 'spot checks'

Compliance department remains independent from operational areas to preserve the audit function; operational staff may assist provided independence is preserved

Include auditing and oversight of first-tier, downstream and related entities (FDRs) and evaluate their monitoring and corrective action of downstream entities

Provide formal reports of completed audits to the Compliance Committee, Hometown Health Board of Directors, Renown leadership and Renown Health Audit and Compliance Committee as appropriate

Compliance Officer may engage legal counsel and take actions including investigation, discipline, corrective action, reporting to agencies, and returning overpayments; notify delegated contractors of changes impacting compliance when applicable

Assess effectiveness of the Compliance Program on an annual basis and report results to senior governance bodies; to ensure independence, compliance department staff may not conduct the formal effectiveness audit

The work plan includes a schedule of auditing and monitoring activities covering the fiscal year

Applicability and Oversight

Documentation Required

Applicability: staff, Board, FDRs and network providers — FDR oversight included

Hometown Health compliance policies and auditing program apply to Hometown Health management and staff, Board members, first-tier/downstream/related entities (FDRs), and network providers; the program explicitly includes oversight of FDR entities as part of monitoring and audit activities.

Scope lists persons and entities: staff (management, staff, contractors, vendors), Board members, officers and managers, FDRs, and network providers.
Purpose statement: program includes oversight of FDR entities and ensures communication among Compliance Manager, Compliance Committee, staff, and stakeholders for oversight of Medicare Part C, Part D and commercial operations.

Key Definitions

Abuse

DefinitionProvider practices inconsistent with sound fiscal, business, or medical practices resulting in unnecessary cost to the Medicaid program, or reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for healthcare (42 C.F.R. 455.2).

ScopeIncludes beneficiary practices that result in unnecessary cost to the Medicaid program.

Regulatory referenceCited federal regulation: 42 C.F.R. 455.2.

Relation to corrective actionsAbuse findings may trigger corrective action to remediate practices and prevent recurrence.

Fraud

DefinitionA false representation of a material fact, whether by words or by conduct, by false or misleading allegations, or by concealment of that which should have been disclosed, which deceives another.

SourceParaphrased from Black's Law Dictionary (policy text).

ImplicationActs meeting this definition may be subject to enforcement by OIG and other authorities.

Monitoring

DefinitionRegular and ongoing reviews performed as part of normal plan operations to confirm ongoing compliance and ensure corrective actions are completed and effective.

PurposeTo monitor remediation of high-risk areas and verify effectiveness of corrective actions.

Frequency contextPerformed as part of routine plan operations (frequency determined by work plan and risk assessment).

Auditing

DefinitionA formal review to assess compliance with a particular set of standards (e.g., policies and procedures, laws and regulations).

UseConducted to evaluate adherence to internal policies, federal/state laws, and regulatory requirements.

OutputFormal audit reports used for follow-up, reporting to governance, and to inform corrective actions.

Corrective Action Plan (CAP)

DefinitionA formal document completed by the business owner and the Compliance department to record the action taken, the responsible person and applicable deadlines to remedy areas of high risk or non-compliance.

ContentMust document actions, responsible persons, and deadlines to remediate non-compliance.

OwnerPrepared by the business owner in coordination with Compliance.

PurposeUsed to track remediation and verify completion of corrective measures identified through auditing or monitoring.

Policy Summary

Payerhometownhealthproviders

PolicyAuditing and Monitoring

Policy CodePolicy Hometown.HCP.007

Change TypeNo material changes

Effective DateMay 1, 2018

Last ReviewAug 19, 2016

Next Review DateMay 1, 2020

Key ActionCompliance policies apply to staff, board, FDRs and network providers; FDR oversight included in auditing activities.

SourceLink

On This Page

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

Auditing and Monitoring

Customize your policy alerts

Sign up for hometownhealthproviders Policy Hometown.HCP.007 alerts

Get alerted when Policy Hometown.HCP.007 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Auditing and Monitoring Program Criteria

Auditing and monitoring program requirements and processes

Develop organizational risk assessment to identify and prioritize risks

ALL of the following

Work plan includes audits to be completed, audit schedules, announced or unannounced audits, internal or external audit, audit methodology, required resources, type of audit (remote desktop or onsite), responsible person, final audit report due date, and follow up and corrective action plans from findings.

Corrective action and follow-up is led and/or overseen by the Compliance Officer; findings may be self-reported to the applicable regulatory entity

Audit types include

Remote desktop audits
Onsite audits
Unannounced audits or 'spot checks'

Compliance department remains independent from operational areas to preserve the audit function; operational staff may assist provided independence is preserved

Include auditing and oversight of first-tier, downstream and related entities (FDRs) and evaluate their monitoring and corrective action of downstream entities

Provide formal reports of completed audits to the Compliance Committee, Hometown Health Board of Directors, Renown leadership and Renown Health Audit and Compliance Committee as appropriate

The work plan includes a schedule of auditing and monitoring activities covering the fiscal year

Applicability and Oversight

Documentation Required

Applicability: staff, Board, FDRs and network providers — FDR oversight included

Scope lists persons and entities: staff (management, staff, contractors, vendors), Board members, officers and managers, FDRs, and network providers.
Purpose statement: program includes oversight of FDR entities and ensures communication among Compliance Manager, Compliance Committee, staff, and stakeholders for oversight of Medicare Part C, Part D and commercial operations.

Key Definitions

Abuse

ScopeIncludes beneficiary practices that result in unnecessary cost to the Medicaid program.

Regulatory referenceCited federal regulation: 42 C.F.R. 455.2.

Relation to corrective actionsAbuse findings may trigger corrective action to remediate practices and prevent recurrence.

Fraud

SourceParaphrased from Black's Law Dictionary (policy text).

ImplicationActs meeting this definition may be subject to enforcement by OIG and other authorities.

Monitoring

DefinitionRegular and ongoing reviews performed as part of normal plan operations to confirm ongoing compliance and ensure corrective actions are completed and effective.

PurposeTo monitor remediation of high-risk areas and verify effectiveness of corrective actions.

Frequency contextPerformed as part of routine plan operations (frequency determined by work plan and risk assessment).

Auditing

DefinitionA formal review to assess compliance with a particular set of standards (e.g., policies and procedures, laws and regulations).

UseConducted to evaluate adherence to internal policies, federal/state laws, and regulatory requirements.

OutputFormal audit reports used for follow-up, reporting to governance, and to inform corrective actions.

Corrective Action Plan (CAP)

ContentMust document actions, responsible persons, and deadlines to remediate non-compliance.

OwnerPrepared by the business owner in coordination with Compliance.

PurposeUsed to track remediation and verify completion of corrective measures identified through auditing or monitoring.