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Utilizing ACL in Healthcare AuditsGoing beyond the obviouswww.hcca-info.org 888-580-8373
About Fairview Health Services 7 Hospitals300 Clinics20,000 Employees10,000,000 Records per month inclinical system 5 Auditorswww.hcca-info.org 888-580-83732
What is ACL (Audit Command Language)Data mining and analysis software– Handles large sets of data– Preserves data integrity– Used by auditors worldwide since 1987www.hcca-info.org 888-580-83733
Uses for ACL in Healthcare Compliance HIPAA privacy review Medicare fraud and abuse Revenue opportunitieswww.hcca-info.org 888-580-83734
Health Insurance Portability and Accountability Act (HIPAA)The Privacy Rule is one of the five AdministrativeSimplification Rules under Title II of HIPAARequires covered entities to have written privacyprocedures, including a description of staff that hasaccess to protected information, how it will be used andwhen it may be disclosed.www.hcca-info.org 888-580-83735
Medical Record Privacy-illicit viewingFind exact matches of patient address to employee address to identifyemployees viewing their family, their own or roommate’s MR.Employee Master DataClinical System Log FilesPat LN Pat FN User LN User FN Emp LN Emp Fn Pat veTonywww.hcca-info.org 888-580-8373DoeJohnsonBrownJaneDaveTonyEmp Add123 Main Street Apt 1 123 Main Street Apt 1789 River Rd789 River Rd456 Crayola Blvd456 Crayola Blvd6
Medical Record Privacy-illicit viewingFind similar matches of patient address to employee address to identifyemployees viewing their neighbor’s MR.A search matching the first 10 characters of the address field would find:Employee Master DataClinical System Log FilesPat LN Pat FN User LN User FN Emp LN Emp Fn Pat AddEmp AddDoeJohnson123 Main Street Apt 1789 River RdJohnDaveDoeJohnsonJaneDavewww.hcca-info.org 888-580-8373DoeJohnsonJaneDave123 Main St Apt 1789 River Road7
Medical Record Privacy-illicit viewingReview MR activity following the visit by a celebrity, politician or anyone wellknown or in the news.Clinical System Log FilesEmployee Master DataPat LN Pat FN User LN User FNEmp LN Emp Fn Emp Job veFredBarneyJaneDavewww.hcca-info.org eHealth Unit CoordNurseHealth Unit CoordAccountantCBO ClerkNurseHealth Unit Coord8
Medical Record Privacy-activity trendsGraph the activity level of users and test outliersEmployees C and Ehave an unusually highnumber of views.Number of views20015010050UserAUserBwww.hcca-info.org 888-580-8373UserCUserDUserEUserF9
Medical Record Privacy-activity trendsGraph the activity level of users by shiftNight shift has an unusuallyhigh number of views giventhat the office workers arenot logged in.Number of views100755025DayShiftwww.hcca-info.org 888-580-8373EveningShiftNightShift10
Controlled Substances Act (CSA)The CSA is the legal basis by which the manufacture,importation, possession, and distribution of certain drugsare regulated.The Drug Enforcement Administration (DEA) is a UnitedStates Department of Justice law enforcement agencytasked with enforcing the Controlled Substances Act.A DEA number is a series of numbers assigned to a healthcare provider allowing them to write prescriptions forcontrolled substances.www.hcca-info.org 888-580-837311
DEA Number AnalysisRecalculate the DEA Number algorithmwww.hcca-info.org 888-580-837312
DEA Number AnalysisUS Dept of Commerce makes DEA data available for purchaseVerify Script DataPharmacy Controlled Substance ScriptsDEA DataPhys LN Phys FN DEA NumWrit Date Phys LN Phys Fn DEA Num Exp org 888-580-8373Algorithm does not computeNumber does not exist in DEA recordsNumber does not exist in DEA 711/30/0713
DEA Number AnalysisUS Dept of Commerce makes DEA data available for purchaseVerify Physician DataPharmacy Physician DataDEA DataPhys LN Phys FN DEA NumPhys LN Phys Fn DEA NumZhivagoZhivagoWeaverAlgorithm does not computeNumber does not exist in DEA 1234563CM9999991www.hcca-info.org 888-580-837314
Tax ID Number Verification Social Security Administration– Better for verifying employees– 2 Options: Upload a complete file of employee data for verification. Online verification– Verifies: SSN has been issuedSSN matches name and birth dateSSN matches genderSSN is issued to deceased personwww.hcca-info.org 888-580-837315
Upload a complete file of employee data for verificationFixed width text file must be formatted as follows:Field NamePositionField SizeField Type1-99NumericEntry Code “TPV”10-123AlphaProcessing Code 21413-153NumericLast Name16-2813AlphaFirst Name29-3810AlphaMiddle Name/Initial39-457AlphaDate of Birth User Control ster ID Code124-1274AlphaMult. Request Indicator128-1303NumericSocial Security NumberGender Codewww.hcca-info.org 888-580-837316
Verify SSN’s Onlinewww.hcca-info.org 888-580-837317
SSN Verification Results1 SSN is not in Social Security Administration’s records2 Name and DOB match; Gender Code does not3 Name and Gender Code match; DOB does not4 Name matches: DOB and Gender Code do not5 Name does not match; DOB and Gender Code not checkedwww.hcca-info.org 888-580-837318
Tax ID Number Verification Internal Revenue Service– Better for verifying vendors– 1 Option: Upload a complete file of vendor data for verification.– Verifies: TIN has been issued TIN matches namewww.hcca-info.org 888-580-837319
Upload a complete file of vendor data for verificationDelimited text file must be formatted as follows:Field NameDescriptionField TypeVendor NumberAlphanumericTIN Type1 Individual2 BusinessNumericTax Identification NumberTIN or SSNNumericVendor NameAlphaAccount NumberVendorwww.hcca-info.org 888-580-837320
TIN Verification ResultsTIN TypeTINNameAccount No Reason Code1123456789DOE, JANE367112987654321Acme Co.510820 Data matches IRS records1 TIN entered is not currently issued2 TIN and Name do not matchwww.hcca-info.org 888-580-837321
Social Security ActSec. 1128 – Exclusion of certain individuals and entities from participationin Medicare and state health care programs.Sec. 1156 – Obligations of health care practitioners and providers ofhealth care services; sanctions and penalties; hearings and review.The OIG, under this Congressional mandate, established a program toexclude individuals and entities affected by these various legal authoritiesand maintains a list of all currently excluded parties called the List ofExcluded Individuals/Entities.www.hcca-info.org 888-580-837322
Verify OIG Excluded Provider Status Download database of excluded providers. Match OIG names with Payroll Master names. Verify “Short List” of name matches online.*Note: The most common excluded provider type is“License Surrender”. False positives often resultbecause employee does not think to have statuschanged. It is not done automatically.www.hcca-info.org 888-580-837323
Download Excluded Provider ListOIG DataLast NFirst NBackSeltzerShowerShoreHelenAlAnitaSandyEmployee RecordsMid NKCwww.hcca-info.org 888-580-8373Last NFirst N Mid 89987654321999999999888888888KC24
Excluded Parties List System (EPLS) Download database of EPLS website.– Database is updated regularly.– Updated for additions and removals. Match EPLS names with Payroll Master names.– Find name matches.– Find matches with alias’. Includes both names and addresses.www.hcca-info.org 888-580-837325
Mail Boxes Etc./UPS Store Address Search Create your own address database.– Addresses provided on website. Match to AP vendors mailing addresses.– Positive matches are a “red flag” for follow-up. Do you know where this vendor is actually located? Should there be a physical address for this vendor? Has this vendor misrepresented their size, status or ability?www.hcca-info.org 888-580-837326
Detecting Employee Fraud using ACL Numerous employees with the same address.Numerous employees with the same back account.Employees in the vendor master file.Missing data in Employee master file.Duplicates in Employee master file.Improper use of earnings’ codes.Improper use of overtime.www.hcca-info.org 888-580-837327
Detecting Vendor Fraud using ACL Split invoices to avoid approval levels.Numerically sequenced invoices.Matches to Employee data (e.g. address, SSN)Missing data elements in Vendor Master file.Use of Managerial override to create vendor.Vendor addresses changes.Payments to dormant vendors.Duplicate payments.www.hcca-info.org 888-580-837328
Before you utilize third party data: Read their terms of use carefully. Consult with your Legal Department.– Don’t run afoul of employment laws.– Establish support for your findings.www.hcca-info.org 888-580-837329
Other uses for ACL Analyze financial data (AP/AR/budget, etc.) Analyze payroll data Analyze the capture of revenues.www.hcca-info.org 888-580-837330
WebsitesDEA Numberswww.deanumber.comSSN andler.do?SUITE IRESBSOIRS ration/Reg Online/Reg RegisterUserFormOIG Searcheshttp://exclusions.oig.hhs.gov/SDN ofac/sdn/MBE/UPS Store uded Parties List Systemhttp://www.epls.gov/Department of Commerce nt/liststocheck.htmCounty and City s/stats/ccdb/www.hcca-info.org 888-580-837331
What is ACL (Audit Command Language) Data mining and analysis software – Handles large sets of data – Preserves data integrity – Used by auditors worldwide since 1987. www.hcca-info.org 888-580-8373 4 Uses for ACL in Healthcare Com
