How to Set Up Internal Audit Procedures to Maintain Your Therapy Clinic’s Compliance

Following legal guidelines is an essential part of running any type of business, but is especially crucial in the therapy field. Though therapy clinic regulations may not be as intense as those for traditional medical specialties, maintaining compliance can still be quite complex. In fact, this is one of the most intimidating factors of starting a therapy clinic, and can be the downfall of a fully operational clinic if audit procedures are not in place.

Since our EMR was built specifically to make it easy for users to comply with HIPAA and Florida CMS guidelines, we understand the ins and outs of audit-proofing your clinic’s protocol and documentation.

To begin establishing internal audit procedures, you’ll first need to thoroughly understand the components of compliance as they relate to therapy clinics. These can vary depending upon the mix of insurance coverage amongst your patients (i.e. the portion of Medicaid patients vs. commercial carrier patients you see). However, some components are true across the board. Here are five key ideas to keep in mind:

  1. Medical necessity. This is an element that many in the therapy world omit from the compliance conversation. However, it’s essential that your documentation reflects the honorable nature of any treatment your therapists provide to patients. According to CMS.gov, including a statement asserting that the therapist believes treatment is medically necessary “supports approval” of a Medicaid or Medicare claim. Therefore, if your office treats patients covered by either public health insurance program, we suggest requiring the medical necessity statement on all documentation that leaves your practice. In our 25+ years of experience with medical billing, we’ve discovered the importance of this verification for the efficiency of approvals, payments, and ultimately, for your patients’ continuity of care. That’s why we’ve included medical necessity checkboxes on all our therapy documentation templates.
  2. Signature and documentation requirements. Hand in hand with the above recommendation, CMS requires that all treatment notes and evaluations be completed and signed within 48 hours of the therapy session. This is both to ensure that the therapist hasn’t forgotten what transpired and can accurately document a patient’s progress, but also for the security of the patient’s records. The time frame of completion is difficult to regulate using paper documentation. With an EMR that locks and time stamps each document, though, any audit personnel will have assurance that you have complied with this rule.
  3. HIPAA. As you should already know, HIPAA is perhaps the most important factor in compliance, as it has been federal law since 1996. Especially if your clinic is growing, it’s imperative to create a mandatory HIPAA training protocol for each new hire. Asking them to sign a statement that they understand HIPAA law does not protect you from potential loss in the event of a violation, no matter how unintentional. It’s a heavy responsibility to ensure that your therapists and admin staff fully comprehend the intricacies of HIPAA and how to comply with everyday office procedures. Yet, it’s absolutely worth your time and effort to close any holes in knowledge that could jeopardize your practice altogether.
  4. Coding and billing. Two of the most significant components in compliance involve the way you keep your business afloat: by submitting and getting paid for the therapy treatments you’ve provided. Thorough documentation is fundamental to a smooth billing process, as are precise units of time. Next is accurate coding. If you rely upon your staff to code treatments in-house, it’s wise to make sure that at least two pairs of eyes fall upon each outgoing evaluation or SOAP note. Completing this manually can increase the room for error, however. When you use TheraPlan, it’s easy for each user to see which CPT codes they’ve filled in on the patient’s most recent document and use a pre-filled dropdown to select the correct code for their specialty. Whether you complete billing yourself or outsource it to an experienced agency, honest and timely billing processes also fall under the umbrella of compliance. 
  5. Miscellaneous administrative factors. These include secure communication with patients, confidentiality, and fair hiring practices. The details may vary based on your practice size and the number of staff you have available to help, but prioritizing organization in all facets of your clinic operations is a good place to start.

If you’ve integrated all of the above factors into your clinic’s procedures, the next step is being able to prove it. In the event of an audit, you’ll most likely be questioned about your protocol for communicating and maintaining compliance in your clinic. Keeping a record of the way you and your staff address each and every requirement can seem overwhelming, but it’s simply a matter of creating a system. Much like you have created a system for payroll, accounting, and other elements of business ownership, this is truly no different. 

As a tech company, we believe in electronic management of internal compliance efforts. Whether you use shared online spreadsheets that track each person’s access and changes or an EMR like TheraPlan, which automatically records each user’s actions within the software, you should find a method you’re comfortable with to track every person who has interacted with documentation and patient records. That way, there’s no doubt as to what has happened in the event of an audit or alleged HIPAA violation. 

Ultimately, compliance is about integrity. Keeping in mind what’s fair and required for all parties, regardless of the amount of effort involved, will protect you in the event of an audit.

Check out TheraPlan’s security-focused software to discover the ways our EMR can simplify this process for you and your staff. 

*Disclaimer: We do not recommend using this blog as your only source of information regarding compliance. Please thoroughly research the regulations that apply to your state and range of specialties prior to preparing your clinic for future audits.