Audits & Training – PDCA

Audits & Training

The quality best practices have been aligned with the well-known and proven method: Plan –Do-Check -Act (PDCA). By utilizing this process, the quality of coding goes into a continual improvement cycle that provides education for all coders as well as recommendations for corrective processes to help minimize errors going forward.

Also See other essentials from the links below.
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Audits & Training

Prospective Audit
  • Review of Claim Prior to submitted for Payment.
  • Generally performed Internally (can be performed by outside consultant/organization for better control).
  • No Fraud Liability/No Fine for over payment, underpayment.
  • Periodic  (Monthly, Quarterly, Annually).
Retrospective Audit
  • Review of claim After submitted for Payment.
  • Generally performed externally (can be performed internally as well).
  • Fraud Liability / Fine if audited by CMS agency.
  • Generally Quarterly and Annually

Elico Quality Audit Services

Objectives

The quality best practices have been aligned with the well-known and proven method: Plan –Do-Check -Act (PDCA). By utilizing this
process, the quality of coding goes into a continual improvement cycle that provides education for all coders as well as recommendations for corrective processes to help minimize errors going forward.

Elico Quality Audit Services

The quality best practices have been aligned with the well-known and proven method: Plan –Do-Check -Act (PDCA). By utilizing this
process, the quality of coding goes into a continual improvement cycle that provides education for all coders as well as recommendations for corrective processes to help minimize errors going forward.

  • PLAN

    The objective of the QA plan is to identify defective samples/charts correct them and initiate a process to check the defects/errors are not repetitive.

    • Identifying the right sample from a given population.
    • Predictive sampling methodology.
    • Random Sampling methodology.
    • Identifying the defects/ defective chart.
    • Error categorization.
    • Ishikawa – Cause and Effect root cause analysis.
    • How to approach the coder with the defects.
    • Identifying training needs.
    • Who, when, how the training will be done.
    • Evaluation of the coder post training.
    • Performance Improvement plan.
    • Timelines.
    • How and when the evaluation will be done.
    • Actions based on the evaluation


  • DO


    Implementation of the plan. The important action part of the entire process.

  • CHECK


    Measurement of the objectives to see they meet expectations. This is an important step, as it allows for the adjustment of the plan where necessary. It also allows for incremental changes instead of a one-shot approach to attaining perfection.

  • ACT


    Implementation of changes identified in the CHECK phase.

Scope of Audit

All charts coded/pended by Elico.

  • QC - 15 % on the daily deliverables coded by Elico.

    Audit scope is the entire population

    • Ex: If 1000 charts coded scope will be from 1 – 1000.
    • Charts are picked for audit after coding is complete.
    • 2 Sampling methodology random and predictive.
      • Random – Any chart from this 1000 volume.
      • Predictive – Level specific, procedure specific, CC,document deficiency, Injuries, DocuCQC charts……etc.

  • QA – 5 % Retro Audit twice in a week.


    QA charts will be separately identified and shared with results to all stake holders both Client and Elico.

  • Focus audit

    • Definition: Focus audit is directing on repeated errors and client complaints.
    • Objective: Under this process a focused audit cover will be provided for agent / ramp-up employee based on their individual quality report. All agents / ramp-up employee who fall under the expected quality % will be part of this audit process.

Quality monitoring methodology

Quality Monitoring gives an idea of how well each of the agent /programs is meeting customer’s requirement.

Zero Tolerance Policy for Violation