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Metrics – 2021Performance ABC Health SystemThis report is intended to provide the board [committee of the board] and senior leaders with regular insight into management’s execution of the compliance and ethics program as well as important metrics related to significant healthcare risks areas facing ABC Health System. In addition, it is intended to facilitate fulfillment of board and management obligations to effectively oversee the development and implementation of an effective compliance and ethics program under the Federal Sentencing Guidelines. Questions regarding the scorecard or our performance are always welcome.I. Compliance Program Performance MetricsTargetQ1Q2Q3Q4CommentsA.Program Operation Leadership, Oversight and Governance Compliance Committee meets quarterly with quorum100%Board receives quarterly Compliance metrics reports100%B.Integration of Compliance into Standards, P&P’s New or significantly modified Compliance P&Ps communicated to affected employees and contractors within 60 days90%pliance Education and Training Leaders complete required annual Compliance, Anti-Harassment and Privacy training by due date98%Employees complete required annual Compliance and Privacy education by due date95%New employees complete required Compliance and Privacy education within 60 days of hire95%Conflict of Interest attestations completed by due date98%D.Open Lines of Communication – Ethics and Compliance Line ReportingCompliance related investigations closed within 30 days75%Privacy/Data Security related investigations closed within 30 days75%Number of calls to compliance hotlineN/ANumber of compliance calls closed “with merit”N/ANumber of alleged privacy incidentsN/ALeaders timely submit quarterly Legal/Compliance disclosure attestation90%E.Excluded Individual Screening New hires are screened against OIG and GSA exclusion lists upon hire100%Existing employees and medical staff members screened against OIG exclusion list monthly100%II. Substantive Compliance/Auditing and Monitoring Performance MetricsTargetQ1Q2Q3Q4CommentsA.Admitting/ RegistrationAdvance Beneficiary Notice (ABN) 95%Medicare Secondary Payer (MSP)95%Medicare Rights Notifications95%Condition of Admission Documentation95%Medicare Outpatient Observation Notice 95%B.Coding/MiddleInpatient coding accuracy rate*95%Outpatient coding accuracy rate+95%IP auditor accuracy rate95%OP auditor accuracy rate95%Physician E&M coding accuracy rate95%Timely production of medical records. (30 days)95%C.BillingMedicare credit balance report CMS-838 filed timely within 30 days of quarter end99%Government payer rebills/refunds completed timely (within 60 days)95%Number of voluntary refunds to governmentN/AThree-day window accuracy95%Government and patient credit balances resolved within 60 days95%D.Care ManagementMedicare admissions reviewed for medical necessity within 24 hours of admission90%CDI/Coding queries appropriately worded95%Clinical denial rates below x10%E.Physician Transactions(anti-kickback, Stark, etc.)No contract services until contract fully executed98%Payments consistent with contract terms98%Physician lease payments timely received95%New leaders complete Physician Transaction training within 60 days95%F.Privacy/Data SecurityAverage number of potentially malicious emails blocked each dayN/AAverage number of potentially malicious intrusion attempts detected each dayN/ANumber of significant security incidentsN/ANumber of confirmed privacy incidentsN/ANumber of patients impacted by confirmed privacy breachesN/AG.Internal AuditAudit Corrective Action Plans implemented timely90%*IP coding accuracy is measured by DRG accuracy (95%) and principal diagnosis, MCC, CC, Secondary DX, discharge disposition, procedure code, POA accuracy and query accuracy (all 90%).+OP coding accuracy is measured by facility E/M, facility CPS, modifier and ICD-10 accuracy (all 90%) individually, 95% overall. ................
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