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A medical records auditor works for a hospital or clinic or is contracted by these facilities to make certain that the medical records are accurate, updated regularly and easily accessible by authorized personnel, while at the same time, kept confidential and secure from non-authorized individuals. She ascertains that records identify the patient, document the diagnosis, rationalize the treatment and report the outcomes. She is in constant contact with administrators and department heads to be sure she clearly understands the area’s goals, standards and objectives.
The auditor is looking for deficiencies that open a facility to liability. For example, there was a case in which a facility billed Medicare for blood tests never ordered by a doctor and another case in which doctors ordered “chemistry profiles,” and the hospital tacked on bogus blood tests. There are instances where fees were charged for x-rays never taken, drugs never administered and time never spent was added to bills. Such fraudulent activities open facilities to liability, law suits and hefty fines. Anyone caught altering records in the wake of an audit has committed a criminal offense and in the case of altering Medicare records the fine is $250,000 and five years in prison.
Gathering and assessing data and information, the auditor selects a random sample of records to audit, comparing his findings against the department or area’s established goals as well as the JCAHO criteria. He may interview people, observe, investigate any impropriety and conduct other investigations as required. After the initial audit, he meets with administrators and department heads to review any deficiencies uncovered and, again, to make certain he isn’t misunderstanding or misconstruing data or procedures. If his findings are correct, the records manager and other personnel can move quickly to amend poor practices, which the auditor can note in his final report.
An auditor usually presents a final report on each audit to department heads and administrators or even with a hospital’s board of directors, to reveal the deficiencies she has uncovered, the solutions already in place to resolve the problem and to discuss any liability the facility may face. The report itself should be readable, with key information easily accessible and reflecting all specific problems. Once the report is presented, the auditor considers the responses it generates and monitors the steps taken to correct the problems uncovered. Occasionally, she will follow up in a month or so to make sure the recommendations and remedies have been implemented.