03/01/91 B

This is the second and supervisory class in the Health Care Compliance Program series for classes that review and analyze Medicaid billing and medical record data to identify abusive utilization of services by recipients and providers. Positions in this class conduct on-site audits of billing and medical record data to identify provider or recipient abuse. This class is distinguished from the Health Care Compliance Program Analyst class by the additional responsibility to audit financial records and conduct reviews on-site. It is distinguished from the Health Care Compliance Program Supervisor class by the latter's supervisory responsibility for a major function in the compliance program.

Complexity of Work: Performs work of considerable difficulty involving the identification and control of abusive billing practices by all types of health care providers and recipients in the Medicaid program through the Surveillance and Utilization Review Audit Program. Organizes, implements and monitors corrective action plan. Investigates cases by conducting audits of medical and billing data for assigned providers. Verifies that the appropriate legal and procedural guidelines are followed when conducting audits. Analyzes and prepares summaries and reports of audit findings for fact-finding conferences and formal evidentiary hearings. Makes recommendations for referral of provider cases to other units or agencies. Responds to inquiries from providers, lawyers and outside agencies on audit-related issues. Reviews and evaluates existing program policies and procedures to determine their effectiveness in deterring abusive billing practices.

Supervision Given: Supervision is typically not a factor.

Supervision Received: Receives general supervision from the Health Care Compliance Program Supervisor. Technical assistance is provided by the supervisor in auditing non-routine or complicated records and in the application of program policy but generally the work is performed independently.

Scope: Positions in this class perform auditing activities affecting the Medical Assistance Program by identifying and monitoring abusive non-program compliance billing practices of all types of health care providers and recipients. Positions present summary information to federal, state, local governments and private organizations.

Impact of Actions: Complete and thorough work and the accurate documentation of audit materials promotes cooperative relations between providers, recipients, health care professionals and the Attorney General's Office. Failure to identify abusive billing practices results in considerable financial losses to the program and the agency.

Personal Contacts: Frequent internal and external contacts with the Medicaid Fraud Unit, clerks of the court, the Office of the Attorney General and with the Department of Health Professionals regarding the development of materials for referrals; internal contact with agency divisions regarding policy, with claims information and referrals for fraud investigations; and external contact with providers regarding billing problems and to explain departmental policy, and with local agencies, professional consultants and the Medical Society of Virginia regarding cases and peer reviews.

Knowledge: Considerable knowledge of the principles of the technical methods of medical/financial auditing, utilization review, and quality assurance; of current health care trends and community standards of practice; and of departmental policies for all provider types. Working knowledge of accounting and legal document analysis.

Skills: None identified for this class.

Abilities: Ability to assess complex medical and financial audit issues; to analyze audit findings; to interpret complex statutes and regulations; to communicate effectively both orally and in writing; and to function as an audit team leader or member.

QUALIFICATIONS GUIDE*

Licenses or Certification: None.

Education or Training: Graduation from an accredited college or university with course work in nursing, quality assurance, medical/financial auditing, accounting or related clinical field principles.

Level and Type of Experience: Considerable experience in medical utilization review, medical financial audits or peer review.

An equivalent combination of training and experience indicating possession of the preceding knowledge and abilities may substitute for this education and experience.

This class was revised by the Department of Medical Assistance

Services, effective March 1991.