Keeping Ahead of the Curve: Auditing Your Clinical Records


Developing a consistent program for auditing your clinical records is critical in ensuring you are mitigating your risk of non-compliance and ultimately non-payment. As we all know, the hospice industry is currently faced with an unprecedented amount of regulatory scrutiny that does not appear to be diminishing any time in the near future. Consistently effective documentation is the only thing that can allow you to undergo such scrutiny with little or no negative results and ultimately save your hospice from even greater scrutiny, which can threaten the long-term viability of the program.

An auditing process is an essential element of an effective Corporate Compliance Program as outlined by the Office of Inspector General (OIG) Guidelines for Hospice Compliance Programs, published in 1999. In that document the OIG clearly states that hospices should conduct internal monitoring and auditing and further identify what they believe to be the greatest areas of risk for hospices. Since that time, the OIG has regularly published the specific areas within the hospice industry they will be investigating. One such area identified in 2013 is the general inpatient level of care, which we focused on in our last blog.

In our consulting practice we see many hospices that are auditing their clinical records; however the approach is frequently haphazard. For example: nurse case managers being pulled in from the field to review their own records and billing clerks with little or no training auditing records for technical compliance with regulatory requirements.  

Best Practices

The person or persons selected to audit clinical records must have the requisite qualifications, experience, time, and tools. Furthermore an annual clinical record audit is not sufficient to ensure compliance and the development of good documentation practices. Weatherbee recommends that hospices:

  • Develop a regular schedule for auditing clinical records;
  • Create a robust tool to use for conducting the audit, developed in collaboration with your QAPI team;
  • Ensure the audit tool includes all the technical and clinical requirements for eligibility (including eligibility for all levels of care);
  • Conduct regularly scheduled audits on a pre-billing basis;
  • Start by reviewing records on a monthly basis for one quarter
  • Select a sample size that allows you to capture all the required technical elements and provides you with a diverse enough population of patients for review (newly admitted patients, 90-day and 60-day recertification, etc.);
  • Include patients who could pose a higher risk for scrutiny such as those with a longer length of stay, who reside in skilled nursing facilities, received higher levels of care, or who may have a less common terminal diagnosis;
  • Share the audit results with members of the QAPI, management and/or interdisciplinary teams, as appropriate;
  • Create a Performance Improvement Plan (PIP) in collaboration with the QAPI team to address any outlier data or aberrant findings;
  • As part of the PIP, develop and provide any remedial education to ensure that staff know how to correct identified issues; and,
  • Repeat the audit to evaluate compliance with the PIP and to identify new risk exposures, if any.

We often suggest beginning with a review of 10% of the current census. If you find significant problems, you may opt to expand the sample size. If you find issues with technical eligibility, you should also review your internal processes to determine whether they are contributing to the non-compliance (e.g., how does the billing department know whether the Certificate of Terminal Illness has been signed, etc.).

Following the implementation of the PIP and staff education, you should see improvements in compliance and documentation. When you feel certain your records fully demonstrate both technical and clinical hospice eligibility, reviews can be decreased (either in volume and/or frequency). However, given the implications of non-compliance, Weatherbee recommends that hospices invest the time to perform clinical record audits on an ongoing basis – especially in higher risk areas such as non-cancer, long length of stay, facility-based patient populations.

Consistent clinical record auditing is one of the strongest defenses you have against claims being denied. It also provides you with a roadmap for the educational needs of your staff, areas where you might be at risk, and ways to minimize that risk.

Additional Resources

OIG Compliance Guidance for Hospice Providers - 

Weatherbee’s Hospice Regulatory Boot Camps 

Posted by:  Sheila Flynn, RN, MSN, Senior Vice President, Consulting Services and Operations, Weatherbee Resources, Inc. & Hospice Education Network Inc.