Improvement of health care delivery in America: medical office compliance certification system implementation

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Content IMPROVEMENT OF HEALTH CARE DELIVERY IN AMERICA:
MEDICAL OFFICE COMPLIANCE CERTIFICATION
SYSTEM IMPLEMENTATION

Thomas Alexander Nowlin, III

_________________________________________________________________

A Project Presented to the
FACULTY OF THE USC SCHOOL OF POLICY, PLANNING,
AND DEVELOPMENT
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF POLICY, PLANNING, AND DEVELOPMENT

December 2012

Copyright 2012 Thomas Alexander Nowlin, III

Dedication

I dedicate this project and the completion of my matriculation at the University of
Southern California to Bettye J. Nowlin, my wife, and to our children Tommy,
Mark and Brett who have unfailingly provided me with the familial support that I
value and will cherish always.

ii
Acknowledgements

This is to extend my sincere, heartfelt gratitude to the members of my project
faculty advisory committee for their guidance and for their attention to detail
throughout the writing process, LaVonna Lewis, Ph.D. (chairperson),
Iris Baxter, Ph.D., Noachim Marco, M.D. , Frank Markland, Ph.D., Professor
Harry Richardson. A special thank you is reserved for Deborah J. Natoli, Ph.D.
Genevieve Giuliano, Ph.D., whose introduction to the art of staying focused has
been invaluable to my candidacy; and to my sister, Barbara Reid., Ph.D. Her
unyielding faith in me has always been highly inspirational and appreciated.

iii
Table of Contents

Dedication ………………………………………………………………… ii

Acknowledgements……………………………………………………….. iii

Abstract…………………………………………………………………… iv

Chapter 1: Introduction…………………………………………………… 1

Sub Chapter 1: Literature Review………………………………. 8
2: Theoretical Background ……………………….. 10

Chapter 2: The American Health Care Delivery System……………… 16

Chapter 3: The Private Medical Office Operations…………………… 22

Sub Chapter 3:…………………………………………………….. 22

∙ Medical Office Physical Plant
∙ Medical Office Business License
∙ Local Civic Business License
∙ State Business Licenses
∙ Physician Licensure and Certification
∙ Policy and Procedure Documents
∙ Patient Arrival Activities
∙ Patient Activities Prior To Clinical Encounter
∙ Medical Billing Activities
∙ Accounts Payable
∙ Purchasing and Stores
∙ Medical Records
∙ Environmental Services

Chapter 4: Medical Office Compliance Certification System………… 36
Development Implementation

Sub Chapter 4:……………………………………………………... 38

• Scope Of The Audit System
• Medical Office Audit
• Medical Office Compliance Audit Instrument
• Medical Office Audit Charges
• Importance Of A Medical Office Audit System

iv
• Staffing Structure Of CMOCC
• Auditor, Training and Licensure
• Auditor Instructor Training Manual
• Use of the Auditor Instructors Training Manual
• Documentation Of Medical Office Audit Findings
• Justification For A Medical Office Audit System

Abbreviations …………………………………………………………….. vi

Abstract…………………………………………………………………… viii

Glossary…………………………………………………………………… 51

References ………………………………………………………………… 52

Exhibits

01 Center For Medical Office Compliance Certification Development
Implementation Audit Application

02 Medical Office Compliance Certification Audit Valuation Work
Sheet

03 Center For Medical Office Compliance Certification Audit
Valuation Report

04 Medical Office Compliance Certification Audit Corrective Action
Plan

05 Center For Medical Office Compliance Certification Audit
Request Acknowledgement Letter

06 Clinical Case Description Sample

07 Potential Manpower Requirements for Fully Operational National
Medical Office Compliance Certification System Implementation

v
Abbreviations

004010X096A1 Sample Billing Code for Provider to
C004010X098A1 Sample Billing Code for Provider
Contractor to CMS
AAAHC Accreditation Association for
Ambulatory Health Care
ABQA American Board of Quality
Assurance

ABQAURP. American Board of Quality
Assurance and Utilization Review
Physicians, Inc.

AHRQ Agency for Healthcare Research and
Quality

AMA American Medical Association

ARRA American Recovery and
Reinvestment Act

ASCA Administrative Simplification
Compliance Act
CML California Medical License
CMOCC. Center for Medical Office
Compliance Certification
CMS Center for Medicaid and Medicare
Services
DEME MAC. Durable Medical Equipment
Administrative Contractor

EMR Electronic Medical Record
FI Fiscal Intermediary

vi
Abbreviations Continued

HIMSS Health Information And
Management Systems Society

HMO Health Maintenance Organization
HIPAA Health Insurance Portability and
Accountability Act
IOM Institute Of Medicine
MOCC Medical Office Compliance
Certification
NAOS National Academy Of Science
NCPDP National Council for Prescription
Drug Program
PVRP Physician Voluntary Reporting
Program
TJC Joint Commission On Accreditation
of Health Care Organizations
WHO World Health Organization

vii
Abstract

This project will provide an audit system that is designed to improve the

delivery of health care at the physician’s private medical office, i.e., the

initial point of service. The new audit system, Medical Office

Compliance Certification Implementation (MOCC) will focus upon the

non-clinical operation of the private medical office.

With accountability embedded in the non-clinical operations of the
medical facility in place, MOCC focuses upon the improvement of health
care delivery in virtually all national private medical offices.
The purpose of the MOCC audit system is to assist with improving the
delivery of quality health care to the patients visiting a private medical
office. With a MOCC audit system in place, the actual providers, at the
point of service, will naturally be much more accountable for their actions,
and the quality of health care delivered will be not only more predictable,
but also more diligent and more cost effective. This is true for both doctors
and staff. When the private medical office is supported by a MOCC
system, there are many tangible benefits; and those advantages trickle
down directly to the patient. The substantial reduction in physician errors
regarding diagnosis, prescriptions and record keeping are all areas that
would be directly improved by an MOCC audit system.

viii
The contribution to improving the quality of life for their patients would
then be
commensurate with the general office level of adherence to the guidelines
set forth by the MOCC itself. The contention of this candidate is that at
any level of compliance, simply having the program in place functions as
a passive yet practical reminder and affirmation of the goals and
objectives that populate every job description in the private medical office
Private medical offices large and small have ancillary departments or
sections that support the clinical examining areas. These departments have

missions critical to the successful operations and to the delivery of quality

health care at any given medical office. Ultimately the owner of the

private medical office is responsible for both the culture of the office itself

and properly delivering health care to its patients in a secure environment.

ix

IMPROVEMENT OF HEALTH CARE DELIVERY IN AMERICA:
Medical Office Compliance Certification System
Development Implementation

Chapter 1: Introduction
The industry of health care delivery has only one service which is
expressed most poignantly in the Hippocratic Oath. It is an oath which in
one form or another has been uttered in earnest or as lore by all doctors
licensed in America as they enter the field of medicine professionally.
Loosely paraphrased it says that a physician takes an oath to keep their
patients safe from harm and to practice medicine properly without fail.
With most retail markets, if the product is too expensive, of inferior
quality or comes with poor customer service, the consumer can easily
choose a different brand. Most of those choices do not include the
consideration of health risk as a part of the decision process. However,
when health care decisions need to be made, the stakes are much higher
There are three major health care issues to consider:
1. Quality
2. Cost
3. Access

1
Measurement is necessary, but not sufficient in and of itself for quality
improvement. The purpose of the national quality measurement and
reporting systems (NQMRS) is to improve quality.
The link between measurement and improvement is critical for ensuring
an appropriate system design. (Berwick, D., et.al., 2003) In the past few
decades, health services research has had some remarkable successes in
developing useful quantitative tools to measure numerous dimensions of
quality. Practical, reliable, and valid measurements exist for such complex
quality dimensions as patient satisfaction, severity adjusted surgical
mortality rates, and appropriateness of tests, therapies and functional
status outcomes. (Medicare Care, 2003)
In this project, the operational measurement is focused upon the non-
clinical activities of the private medical office. The United States
healthcare industry is arguably the world’s largest, most inefficient
information enterprise. (Freeman, H.E., et.al., 1987) Health absorbs more
than $1.7 trillion per year – twice the Organization for Economic
Cooperation and Development (OECD- average – premature mortality in
the United States is much higher OECD averages. Most medical records
are still stored on paper. So, in effect, they cannot be used to coordinate
care, or to routinely measure quality, or to reduce medical errors across the
board.

2
Also, consumers generally lack the information they need regarding costs
or quality to make informed decisions about the health care provider for
which they are about to choose. It is widely believed that broad adoption
of electronic medical record (EMR) systems will lead to major health care
savings, reduce medical errors, and improve health. Unfortunately
however, there has been little progress toward attaining these benefits. The
United States trails behind a number of other countries regarding the use
of EMR systems. Only 15% - 20% of U.S. physician offices and 20% -
25% of hospitals have adopted systems of this kind. Typical reasons for
not implementing a system like MOCC include: cost, lack of certified
personnel, the practice is not standardized, privacy, and a general
disconnect with the fiduciary aspects of the system. e.g., liability for EMR
systems or speculation regarding the return on investment and whom the
benefactors might be. (Health Affairs, S/O, 2011)
In 2003 the RAND Health Information Technology (HIT) Project team
initiated a study to:
(1) Better understand the role and importance of EMRs in improving
health care, and

(2) Amend government policies that could maximize the benefits of
EMRs and assist in the proliferation of its use

Effective January, 2011, the Center For Medicaid and Medicare will
decline services of non-electronically submitted medical claims.
A study was conducted by the American Hospital Association (AHA)

3
2000 Hospital Survey, and the Healthcare Cost and Utilization
Project(HCUP) 2000 National Inpatient Sample – used to distribute the
errors across hospitals and patients.
A spreadsheet model was then used to calculate “the potential adverse
drug events” and “costs avoided as a function of hospital size and patient
age”. For ambulatory care, the model used error and adverse drug event
reductions reported in the literature for ambulatory services. (CPOE).
Using the 2000 National Ambulatory Care Survey (NAMCS) database on
office visits, the authors extrapolated the effects of an EMR system
embraced nation-wide and show the likely distribution of possible savings
and adverse drug events avoided as a function of practice characteristics
and size. (Freeman, H.E., et.al., 2005)
There are a few published estimates of the cost of widespread
implementation of EMR systems in the United States. Samuel Wang and
his colleagues have constructed a model for estimating the cost and return
on investment for a physician’s office .
Jan Walker and his colleagues have estimated the cost to be $28 billion
per year over a ten-year deployment; and $16 billion per year thereafter
with net savings in the range of $21.6 - $77.8 billion per year depending
upon the level of standardization.
The Patient Safety Institute estimates the initial cost of widespread

connectivity of EMR systems to be $2.5 billion. (Health Affairs,

Sept.-Oct. 2005).
4
Between 1982 and 1986, the average use of medical care declined across
all sectors of the population. In fact, a full one third of Americans did not
visit a physician even once in 1985. The average number of per capita
visits to a physician declined by 10%, a consequence of the reduced
portion of the population with any ambulatory contacts in 1986. (Health
Affairs, 1987) Data related to the number of visits people make to both the
doctor’s office and many hospitals never provide full disclosure in a
transparent, verifiable way, “ do not tell all we wish to know about the
accessibility of health care in the United States. “
An important measure of equity of access is the frequency of the
use of health services by minorities. Hispanics, on average, see physicians
at about the same rate as whites. This social phenomenon is predominantly
due to entitlement exploitation. For the American Negro, the battle is
clearly uphill.
A 1986 survey indicates that access to medical care for black Americans is in
steep decline. By 1986 the delta between blacks and whites is of particular
concern in light of evidence recently assembled by the National Institute of Health
showing that black Americans have a considerably higher mortality rate than their
white brethren. (Freeman, H.E, et. al., 1987)
Health insurance continues to be an important factor influencing access to
medical care. In America, people who have health insurance live longer, healthier
lives than those who are uninsured.
5
Overwhelmingly, the nation’s uninsured reside below the poverty line. In
fact, there is a virtual chasm between the insured and uninsured regarding the
average number of physician visits widened substantially in 1986, suggesting that
the uninsured are challenged with the process of obtaining quality physician care
and finding it increasingly difficult. The Americans who endure these social
frustrations are disproportionately minorities and the poor.
Today, a third of Americans cannot afford health care insurance.
(Congressional Budget Office, 2004) The poor and the elderly have limited access
to medical services; and largely the services to which they do have access are
wrought with the poor management and high potential for medical errors and
unsafe conditions.
Health care reform in America has been a key topic of national debate for

many years. Regardless of the forum, the issues surrounding this topic have
remained volatile right up to this morning’s newspaper. The reason for the
powder-keg nature of the subject boils down to perspective.
To improve the health care system, all facets of the delivery system must
be addressed: (Chassin, M., 1998) ambulatory care (origin of acute care), hospital
care (in-patient care) and many other facilities that cater to the out-patient/client
are concerned about the safety and well-being of those patients. Medical offices
large and small have ancillary departments or sections that support the primary
clinical examining areas and those departments are critically important to the
business operations of the entire facility.

6
The clinical components of the office depend upon the efficiency of those
departments, proficiency of their staff and the security of the patients in the office.
It is the responsibility of the service provider to ensure the proper and safe
delivery of health care to the patient/clients. The consistent continuity of care for
those who enlist the services of the medical office are of pinnacle concern for all
top level office of medical administration.
Current national healthcare reform efforts are missing a critical
component. Today’s health care reform efforts fail to consider the physician’s
private medical office.
To address this concern with the intention of providing a solution, I am
introducing the Medical Office Compliance Certification system (MOCC). With
a focus riveted upon the non-clinical operation of the private medical office, the
MOCC endeavors to create a model of success which will in turn function as a
template for a turnkey system.
Fruition would be evidenced by a congressionally supported national
implementation.
As of January 1, 2009, The Center for Medicaid and Medicare Services
(CMS), has directed its non-audit attention to the clinical operation of the office
via the Physician Voluntary Reporting Program (PVRP). (CMS, 2007) This
project proposes a joint MOCC//CMS audit that would provide the
patient/consumer with the assurance that the medical services rendered at that

7
medical office were safe, efficient, and thorough, bearing evidence of independent
quality certification.
Sub-Chapter 1 - Literature Review

There is an urgent need for non-clinical operations improvement in the

Private medical offices sector of America. (Chassin, M., 1998)

Never, in the history of private medical practice has there been an audit program
that has as its focus, the non-clinical component of the medical office.
In its 2000 report, the World Health Organization ranked the United States

at 34
th
among the industrialized nations of the world in health care delivery. In

2006, the National Institute Of Medicine reported that, American Medicine was in

danger of delivering an inferior product to the American public in large and small
communities. There are legitimate reasons for these dismal results. The primary
inspiration for patients visiting a medical office is to resolve discomfort or illness.
Invariably consumers are confronted with obstacles, some of which are
insurmountable. Filling out insurance forms, medical reports, or the logistics
involved with scheduling are some of the non-clinical activities that can keep
quality health care at bay for far too many Americans. MOCC is a system that can
intervene and check, then subsequently reverse the quality of average health care
at a private medical facility in this country. These non-clinical activities in
particular must be considered and resolved. If those aforementioned concerns
were not important to the patient, they would likely not have been mentioned.

8
All aspects of the medical practice, clinical and non-clinical impact the positive
out-come of the patient’s visit to the medical office. This project is designed to
audit the non-clinical activities of the private medical office. The support
opportunities that it will provide to the clinical and non-clinical staff will enhance
the quality of health care delivery and assist that level of care with regularly
scheduled maintenance. The non-clinical activities associated with the
implementation and utilization of information technology, will greatly improve
the speed of the health care delivery system as well as making it more cost
effective.
There are organizations, e.g. American Medical Association, that present

the arguments, that the start-up cost involved in purchasing electronic hardware is

prohibitive and the human resources necessary to operate the new systems would

increase the operation of the medical office. The physician community is highly

fragmented, numbering in the hundreds of thousands, with more than sixty

percent of office based physician in single or small practice of four doctors or

fewer are concerned about the affordability of information systems. (AMA, 2011)

The American Association Of Ambulatory Care and the health care industry

project the digitizing of medical records could save the nation’s health care

system hundreds of millions of dollars and would reduce or eliminate redundant

testing and the occurrence of errors in patient files and medicinal prescriptions.

(AAAC, 2007)

9
Sub-Chapter 2 : Theoretical Background

No species of fallibility is more important or less understood than

fallibility in medical practice. The physician’s propensity for damaging error is

widely denied, perhaps because it is so intensely feared. Patients who suffer at the

hands of their physician often seek compensation by invoking the procedure of

malpractice claims. Physicians view such claims as perhaps the only outcomes

most earnestly to be avoided, more than even the damaging errors from which

they presumably arise. (Gorovitz, S., MacIntyre, A., 1976)

A major medical malpractice crisis is unfolding in the United States.

The American Medical Association has identified eighteen states in which

physicians and institutional health care providers are having increasing difficulties

obtaining affordable, professional liability insurance. (Danzon. P., 1978)

In the past two years, insurance premiums in these states have increased

dramatically for physicians in high risk specialties such as obstetrics, emergency

medicine, general surgery, surgical subspecialties and radiology.

Another twenty-six states are on “orange alert”, with indicators suggesting a

serious and worsening situation. Compounding the causes for expensive medical

liability are physician errors and the misdiagnosis of patient illnesses.

(Millenson, M. 2006)

Intensifying the situation is the loss of medical records, illegible clinical

documentation and illegible medical pharmaceutical prescriptions.

The high cost of medical professional liability insurance is a source of growing

10
concern among policy makers, health care consumers and the medical profession.

While the concern is widespread, to date, there has been little quantitative

evidence on the over-all economic impact of the problem.

For many years politicians and insurance companies could proclaim that the USA

had the best health care system in the world, but as its major shortcomings

become more visible, Americans are finding it harder to accept this assertion. The

42.6 million citizens in America currently without health insurance are acutely

aware that, our health care system is not working for everyone and there is

growing recognition that the major problem of rising costs and lack of access

constitutes a real crisis. (Navarro, V., 2000)

In 2003, the United Kingdom government’s National Audit Office

published an international comparison of ten different health care systems in ten

developed countries, nine universal systems against one non-universal system that

of the United States with their relative costs and key health outcomes. A wider

international comparison of sixteen countries, each with universal health care, was

published by the World Health Organization in 2004. It was in this comparison

that the United States ranked 34
th
among the industrialized countries

participating. (WHO, 2010) In some cases government involvement also includes

directly managing the health care system, but many countries use mixed public-

private systems to deliver universal health care.

Most current universal health care systems were implemented in the period

following the World War II as a process of deliberate health care reform,

11
intended to make health care available to all in the spirit of Article 25 of the

Universal Declaration Of Human Rights of 1948. This article was ratified by

every country that signed the declaration.

The United States which did not ratify the social and economic rights section,

including Article 25’s universal right to health. The early seventies

witnessed a rapid increase in the frequency and severity of medical malpractice.

In California, for example, both frequency and severity increased at an average

rate of almost twenty percent per annum, cumulating to yield an increase in total

claim cost per physician of roughly forty percent per annum. As striking as the

growth over time is the variation among states.

For example, in 1976 there was an eighteen fold range in malpractice claim

frequency, per capita or per physician, and a thirty fold range in severity.

(Danzon, P., 1978)

At the time of the 1975 medical malpractice “crisis” the explosion of claims was

attributed to various factors :

▪ increased in number and complexity of medical treatments
▪ pro plaintiff trends in common law in general
▪ demise of charitable immunity defense
▪ increase in number of lawyers
▪ erosion of physician-patient relationships

In response to the crisis, tort “reforms” were enacted in most states during 1975

and 1976. These measures vary in detail from state to state, but their common

purpose is to control claim cost by limiting the size of the reward.

Physicians are traditionally liable under a negligence rule liability. Economic

12
analysis of liability rules including malpractice, assumes that the primary function

of liability is injury prevention (deterrence). (Danzon, P., 1978)

Policy makers often attempt to address the symptoms of the American health care

crisis through short term, patchwork solutions under the pressure of time and the

constraints of political decision making, rather than by analyzing the system as a

whole.

One important step in searching for effective longer term solutions is to

ask a deceptively simple two-fold question: how can we know whether a health

care system is both good – that is how well it does the job and fair in terms of

financing health cost delivery ? If we can then analyze how well our health

system performs, in comparison to other countries in the world, we will have a

basis from which to explore possible alternatives. (WHO, 2000)

The World Health Organization (WHO) released a groundbreaking report in

2000, with data on health systems of 191 member countries. In this analysis

WHO developed three primary goals for what a good health system should be:

1. Good Health – making the health status of the entire population as
good as possible across the whole life cycle

2. Responsiveness – responding to people’s expectation of respectful
treatment and client orientation by health care
providers

3. Fairness in Financing – ensuring financial protection for
everyone, with costs distributed
according to one’s ability to pay

13
The WHO study also distinguished between the overall “goodness” of health care

systems (the best attainable average) and “fairness” (the smallest feasible

differences among individuals and groups).

A health system which is both good and fair would thus ideally have:

1. Overall good health (e.g. low infant mortality and high
disability-adjusted life expectancy)

2. A fair distribution of good health (e.g. low infant mortality and long
life expectancy evenly distributed across population groups)

3. A high level of overall responsiveness

4. A high level of overall responsiveness across population groups

4. A fair distribution of financing health care (whether the burden of
health cost is fairly distributed based on ability to pay) so that
everyone is equally protected from the financial risk of illness
(WHO, 2000)

These factors are the same items that were a driving force in health care reform in

1965 when the 89
th
United States Congress passed the Social Security Bill that

allowed the formation of Medicare – health insurance for the elderly and/or

disabled persons and Medicaid – health insurance for the economically poor.

At this point in time the Center for Medicare and Medicaid Services (CMS) is the

largest health insurance carrier in the world with an operations budget of seventy

billion dollars. (U.S.) (CMS, 2009) This act of reform has, and is now providing

and making health care accessible to approximately one hundred million

citizens who would otherwise not have access at all.

The balance of the nation’s citizens – more than two hundred million

who do not qualify for these federal health care benefits, must arrange for health

14
insurance coverage by other means.

Other than hospitals, the majority of private medical offices or similar

facilities for CMS beneficiaries, including private health insurance carriers, are

not audited for compliance or to a standard of performance for the delivery of

quality health care. With such a poor rank in the world regarding health care

among industrialized nations, the members of the American health care industry

acknowledged this ranking as accurate. (IOM, 2000)

In response, the national health care industry has promoted various initiatives

directed toward improving the delivery of health care in America. With

supporting evidence that medical practitioners are delivering an inferior product

– health care – the industry has chosen to address certain clinical and process

components of its practice but has failed to show any concern for the entire

medical office operation. The flaw in this approach is that the patient’s visit to the

facility is not for clinical services only. A visit involves the entire office and every

member of the staff whether it be direct clinical encounter with the physician

and/or other qualified clinical staff or non-clinical business operations and support

staff. The audit that this proposed system is suggesting applies to the non-clinical

activities of the entire medical office and its responsibilities to the well-being and

safety of the consumer patient.

15
Chapter Two : The American Health Care Delivery System

The American health care delivery system is fractured to the point that it is

In danger of allowing its private medical practitioners to deliver inferior health

care services or, because of cost, disallowing accessibility to its citizens.

(Millenson, M.L., November, 2006)

The improvement of the nations’ health care system must address all

facets of the delivery system. Ambulatory care (where health care begins),

hospital care (where health care continues) and many other clinical venues that

are concerned about the safety and well-being of the patients that are demanding

the attention of the nation’s physicians. Seventy percent of all initial medical

encounters begin in the private medical offices or emergency facilities in

America. (AAAC, 2011)

Adults and minor aged children come to these facilities by way of family

members, friends, other practicing physician referrals, advertisements or health

plan direction. When the first visit to the medical office is a non-emergency

encounter, the receiving attendant is expected to provide the incoming potential

patient with appropriate source documents. These documents will serve to

identify the patient, provide personal information, purpose of the visit, and

pertinent information of the health insurance carrier or method of payment for

services.

President Harry S. Truman in 1949 verbally lamented the same health care issues

that are currently affecting the national health care system.

16
The following is a list of factors that Truman noted that continue to have a

negative impact on the health care industry in the first quarter of the 21
st
century:

▪ absence of universal health care
▪ physician error
▪ high cost of health care (Antos, J., 2005)

In 1996, the National Round Table on Health Care Quality was convened by the

Institute Of Medicine (IOM), a component of the National Academy of Science.

The Round Table was comprised of twenty representatives of the private and

public sectors. Practicing physicians, nurses, representatives of academia,

business, consumer advocacy, health media and heads of federal health were in

attendance. This group of professionals met six times between February 1996

and January 1998. It explored ongoing, rapid changes in health care and the

implications of these changes for the quality of health and health care delivery in

the United States. The National Round Table on Health Care Quality concluded

that the quality of health care can be precisely defined and measured with a

degree of scientific accuracy comparable with that of most measures used in

clinical medicine. Serious and widespread quality problems exist throughout

American Medicine. (Chassin, M., 1998)

These problems, which may be classified as underuse, overuse or misuse, occur

in small and large communities alike, in all parts of the country, and with

approximately equal frequency in managed care and fee-for-service systems of

care. Large numbers of Americans are harmed as a direct result of faulty

delivery systems. (Audet, A., et.al., 2005)

17
Current efforts to improve health care delivery will not succeed unless the

nation’s cadre of trained practitioners undertakes a major systematic effort to

overhaul how we deliver health care services.

The Center for Medicare and Medicaid Services (CMS) has initiated a voluntary

clinical improvement program entitled Physician Voluntary Reporting Program

(PVRP) with an effective date of January 1, 2009. The purpose of the program is

to improve the clinical performance of the practicing physician in the private

medical office. The following table is an example of the comparative differences

in the CMS—PVRP program and what this mandatory audit system (MOCC) for

all private medical offices is proposing: (CMS, 2008)

Physician Voluntary Reporting Program
(PVRP)
Medical Office Compliance Certification
(MOCC)

▪ Physician program participation is
Voluntary.

▪ The PVRP program assumes that all
Physicians will follow the clinical
mandates of CMS without any
monitoring of consideration for
operation of the practice.

▪ The PVRP program addresses the
clinical component of the physician’s
medical practice ONLY.

▪ There is no assessment of Penalties if
the physician is a non-participant in
the program or is not adherent to the
CMS clinical guidelines.

▪ The Medical Office Compliance
Certification Audit is Mandatory to
all practicing physicians with a private
medical office.

▪ The physician’s medical office is
regularly audited (every five years) by
an independent agency.

▪ All non-clinical aspects of the
physician’s medical office are audited
to determine compliance to a standard
of performance for the delivery of
quality health care.

▪ If the physician’s medical office is
found to be Non-compliant, the
penalties can be very severe .

Health care disease surveillance has been the domain of the Department Of Public

Health for the past fifty years.

18
It was not a regularly scheduled event. The public would register a complaint

against a physician, facility or institution. The local Department of Public Health

would then respond to the complaint, the department would resolve the complaint

and administer appropriate resolution of the situation in the public interest.

The American College of Surgeons was the sponsor of the first non-profit

organization formed to monitor the safe delivery of health care in hospitals. This

organization was charged with the responsibility of changing the reputation of

hospitals from being “death houses.“ In the first quarter of the 21
st
century, except

for hospitals, nursing homes, long-term care facilities and hospice facilities, all

other facilities that deliver health care services are visited by the Department of

Public Health by invitation of the facility to investigate situations that are a threat

to public safety. Although private medical offices, urgent care centers, and

emergency centers are facilities or organizations for health care delivery, they are

not sites that have regularly scheduled surveillance protocols. These

aforementioned sites represent the origin of more than seventy percent of

physician errors. (Millenson, M.L., 2006)

The Joint Commission On Accreditation Of Health Care Organizations

(TJC) formerly known as the “Joint Commission” has accredited hospitals for

more than fifty years and today accredits approximately 4,250 general hospitals,

children hospitals, long term care facilities, psychiatric hospitals, rehabilitation

and surgical specialty hospitals and 358 critical access hospitals through a

separate accreditation program. The clinical and operational regulatory protocols

19
that TJC has brought to the American hospitals, are the same audit mandates that

are needed by the nation’s 719,269 private medical offices. (Exhibit 8)

Approximately 88% of the nation’s hospitals are currently accredited by TJC.

The Commission’s standards address the hospital’s performance in specific areas

and specify requirements to ensure that patient care is provided in a safe manner

and in a secure environment. The Joint Commission develops its standards in

consultation with health care experts, providers, researchers, measurement

experts, and consumers. (TJC, 2001)

For 2009, the standards-based performance areas for hospital are:

▪ Environment of care ▪ National Patient
Safety Goals

▪ Emergency Management ▪ Nursing

▪ Human Resources ▪ Provision Of Care,
Treatment Services

▪ Infection Prevention and Control ▪ Performance
Improvement

▪ Information Management ▪ Record of Care,
Treatment Services

▪ Leadership ▪ Rights of the
responsibilities Individual

▪ Life Safety ▪ Transplant Safety
(TJC, 2010)

Information about the safety and quality of accredited hospitals is available to the

public at Quality Check® www.qualitycheck.org . This comprehensive listing

includes each hospital’s name, address, telephone number, accreditation status,

20
effective date of accreditation and its Quality Report. Quality Reports include

detailed information about a hospital’s performance and how it compares to

similar hospitals. (TJC, 2010)

21
Chapter Three : The Private Medical Office Operations

Operational accuracy and efficiency in the medical office is essential to

the product being offered to the public. The practitioner has the unique

responsibility of being in charge of the lives of patients who visit the practice for

services. This proposed system is designed to provide the medical physician with

a regular update of the non-clinical activities of the delivery system.

If, following the initial medical examinations, the attending physician should

determine that the patient should be seen by a medical specialist who is trained

and licensed to treat the preliminary diagnosis, a referral will be made. With the

consult and agreement of the patient, the medical office staff will then arrange for

an appointment with a consulting physician specialist.

Documentation of the patient’s visit and the associated clinical encounter is a

mandatory function of the medical office operation. The documentation is

recorded manually (hard copy) or electronically into the patient’s medical record

and is secured in an accessible manner that is immediately available to the patient,

the attending physician and/or referred physician and office medical staff.

Sub Chapter Three - Medical Office Physical Plant

The design and/or location of a medical office must consider the following

characteristics: (AAAC, 2008)

∙ Adequate public access

∙ Adequate and accessible automobile parking, including handicap access

∙ Adequate exterior address signage of the building or physical structure of
the medical office

22
∙ Adequate interior signage showing directions and suite/office numbers

∙ Adequate handicap access to upper floors

∙ Adequate waiting room space and seating accommodations for an
estimated number of patients and/or attendants

∙ Adequate space to provide efficient and competent medical office patient
reception protocol and appropriate business activities

∙ Identified and adequate space to provide medical office business activities

∙ Identified and adequate space to provide medical office clinical activities

∙ Identified and adequate space to provide secure patient medical records

∙ Identified and adequate space to conduct clinical laboratory procedures, if
necessary

∙ Identified and adequate space to conduct clinical radiology diagnostic
procedures, if necessary

∙ Identified and adequate space to conduct physical therapy procedures, if
necessary

∙ Identified and adequate space to provide storage for supplies and
equipment

∙ Identified and adequate space to provide secure space and storage for
pharmaceuticals and/or medicinal supplies

∙ Identified and adequate space to provide environmental services and
biological and/or radioactive waste disposal (NAICS. 2008)

Medical Office Business License

The business operation of a medical office is no different from any other

business. The offered product is medical care service to the public. For

this provision of service, revenue is generated. The profit from the

revenue is taxable to the United States Department of the Treasury,

Internal Revenue Service.
23
The city, county, or state where the medical office exists requires a

business license to conduct business in the governing jurisdiction.

Most city, county and state governments may also require the medical

physician to secure special licenses or permits. (NAICS, 2008)

Local Civic Business License

The general business license where the medical office is located grants the

business owner the privilege of legally operating a business in a certain

city and/or county jurisdiction. Fees are typically low and these types of

licenses are easy to obtain though application procedures may vary.

To obtain a local business license:

1. Have the proposed business paper work in order, including any
fictitious name certificates and the Employer Identification
Number. (EIN)

2. Contact the city hall and/or county offices that governs the
jurisdiction of the business to determine the type of license that
is needed and obtain the necessary application paper work.

3. Complete the application and file it in person with the
appropriate office of jurisdiction along with the fee.
Once the license is granted, file renewals are to occur in a
timely manner. Renewal fees are generally paid annually.
(NAICS, 2008)

State Business Licenses
State business licenses are issued to businesses that provide products or

services as regulated by state law. For example, special state licenses are

required for lawyers, hairdressers, realtors, auto mechanics, private

investigators, building contractors and others who must meet state

24
licensing requirements – i.e., level of “certified” training or education.

State licenses are also required of businesses that must meet certain state

standards or codes, as do restaurants and establishments that serve

alcohol. Each state has separate agencies that regulate different types of

businesses. To obtain a state license:

1. the business owner must contact the local government offices to
determine if the particular business requires a state license. On-line
internet access or public libraries are another good source for specific
licensing information.

2. contact the state office that governs the city of jurisdiction.

3. the requesting physician must complete the application and file it with
the appropriate office of jurisdiction along with the fee. This activity
requires a personal appearance. Once the license is granted, file
renewals are to occur in a timely manner. (NAICS, 2008 )

Physician Licensure And Certification

The new potential patient has every right to any requested information

regarding the training, licensure and medical specialty certification that is

normally publicly displayed inside the clinical areas of the office. If

professional documentation is not displayed, it is appropriate for the

patient to request for verification of any appropriate inquiries.

To practice medicine in the United States, the physician must be licensed

by the state where the medical office practice is located. If the physician

has offices in multiple states, multiple licenses for each state is mandatory.

(CMS, 2010)

The American Board of Quality Assurance (ABQA), upon certification

25
examination, certifies that a physician is certified to practice medicine in

the United States and is certified for the medical specialty indicated and all

clinical activities associated with the practice. Certification examinations

occur at different times in different states. (ABQAURP, 2010)

Policy And Procedure Documents

Every department in the medical office has operational activities that are

designed to deliver quality results. To ensure that the members of the

office staff produce the desired results of their assigned duties, the

management team of the office must develop and publish policy and

procedure manuals for every department.

These documents are authorized and signed by the medical director or

owner practitioner and should be designed to sustain a repetitive level of

quality that is consistent with the safety, health and well-being of the

consumer patient who visit this medical office for health care services.

Patient Arrival Activities

The potential patient -- whether new or returning -- begins with

preparation for arrival at a scheduled appointment date and time. Some

returning patients may correctly know the location of the medical office.

Others, if new patients, may be coming to the office for services for the

first time. Whatever the case, the staff person arranging the appointment

should inquire if there is a need for directions to the medical office. The

office receptionist should be sensitive to the level of anxiety of the patient

and/or the person accompanying the patient.
26
The medical office staff might improve the health delivery experience, if

the following items are offered for consideration at the time the

appointment is made by telephone or in person:

▪ How will the patient be coming to the medical office? Alone or with
someone

▪ Handicap access availability for those persons having a need for the
accommodation(s)

▪ Location of bus stops or parking facilities

▪ Name and address of the building or medical office and
where the office sign is located on the building, e.g. front,
side, top, street level, etc.

▪ Location of escalator or elevator service if appropriate

▪ Location of medical office suite number

▪ Importance of appointment delays or changes

▪ Policy on first visit billing

▪ Adult or minor aged patients being accompanied by a responsible
attendant should be prepared to respond to staff inquiries on behalf of the
patient. e.g., immediate distress, relationship to the patient, patient next of
kin, patient residential address, reason for the visit, need for a wheel chair,
etc.

▪ The medical office will accept approved credit//debit card as a method of
payment for services rendered

▪ This office will accept a current, approved health plan card

▪ This office will accept electronically approved health insurance card(s)

Patient Activities Prior To Clinical Encounter

Before the patient is seen by the physician, registered nurse, nurse

practitioner, or physicians assistant, the patient will be seen by a

27
staff technician who will perform intake procedures e.g., phlebotomy (blood

drawing), body blood pressure, body temperature and body weight. In the

absence of electronic medical records (EMR), the staff will prepare a hard copy

hand written patient medical record to be made available to the physician

attending the patient.

If the patient medical record is not available because it is lost, misfiled or not

prepared, the following must occur:

▪ New medical record must be prepared

▪ Patient medical history must be re-documented

▪ Previous diagnostic procedure values must be re-captured

▪ Medicinal prescriptions must be re-captured from the dispensing
pharmacy, if possible

All of the aforementioned incidents are the type of items that cause health care

delivery expense to be on the increase. This is not due to physician error but, it is

the physician’s responsibility. In the presence of current and appropriate

technology combined with concomitant policies and procedures, the probability of

recurrence would be remote. The physician treatment plan would not be

delayed and the patients’ care would not be compromised.

Medical Billing Activities

In the first quarter of the 21
st
Century, internet technology is at the

forefront of the move to bring the industry of health care delivery up to par.

Consider the following: claims submission protocol to the Center

of Medicaid and Medicare Services. (CMS) have changed.

28
Medical service claims may be electronically submitted to a Medicaid or

Medicare carrier. Durable Medical Equipment Administrative Contractor

(DME MAC) or a fiscal intermediary (FI) from a provider’s office using a

computer with software that meets electronic filing requirements as established

by the HIPAA claim standard. (CMS, 2010) Medical office providers can

purchase software from a vendor or contact a billing service or clearinghouse that

will provide software or programming support. HIPAA compliant free billing

software that is supplied to Medicare carriers, DME, MACs and FIs.

Medicare contractors are allowed to collect a fee to recoup their cost up to $25.00

if a provider request a Medicare contractor to mail an initial disk or update disk

for the free software. (CMS, 2010)

If the medical office that is being audited is currently submitting hard copy claims

to CMS, the auditor will alert the Medical Director and /or the Supervisor of

medical billing department that hard copy medical claims submitted to CMS will

soon be rejected and returned to sender. (CMS, 2010) This activity is

consistent with the CMS to be in compliance with the Administrative

Simplification Compliance Act (ASCA) requirement that claims be sent to

Medicare electronically as a condition of payment. (CMS, 2011)

The medical office should be aware that private health insurance carriers are not

far behind in demanding that these required claims submittals, e.g., Blue Cross

(Anthem), Aetna, Liberty and many others are currently tooling their health

insurance companies to receive electronic medical billing.

29

How electronic claims submission are processed:

▪ The claim is electronically transmitted in data “packets” from the
providers computer modem to the Medicare contractor’s modem over a
dedicated telephone line.

▪ Medicare contractors will perform a series of edits.

▪ The initial edits are to determine if the claims in a batch meet the basic
requirements of the HIPAA standard.

If errors are detected at this level, the entire batch of claims would be rejected for

correction and resubmission. Claims that pass these initial edits, commonly

known as front-end edits or pre-edits, are then edited against implementation

guide requirements in those HIPAA claim standards. If errors are detected at this

level, only the individual claims that are included in those errors would be

rejected for correction and resubmission. Once the first two levels of edits are

passed, each claim is edited for compliance with Medicare coverage and payment

policy requirements.

Edits at this level could result in rejection of individual claims for

correction or denial of individual claims. (CMS, 2010)

In each case, the submitter of the batch or of the individual claims

is sent a response that indicates the error for the denial. After successful

transmission, an acknowledgement report is generated and is either transmitted

back to the submitter of each claim or is placed in an electronic mailbox for

downloading by the submitter. Electronic claims must meet the requirements in

the following claim implementation guides adopted as national standards under

30
HIPAA:

▪ Providers billing an FI must comply with the ASC X12N 837 Institutional
Guide (004010X096A1)

▪ Providers billing a Carrier or DME MAC (for other than prescription
drugs furnished by retail pharmacies) must comply with the
ASC X12N 837 Professional Guide (004010X098A1)

▪ Providers billing a B DME MAC for prescription drugs furnished by a
Retail Pharmacy must comply with the National Council for Prescription
Drug Program (NCPDP) Telecommunications Standard 5.1 and Batch
Standard Version 1.1 (CMS, 2010) (Medicare Claims Processing
Manual Pub. 100-104, Chapter 24)

The National Council For Prescription Drugs Program telecommunication

standard version 5.1 and Batch Standard version implementation guide (NCPDP)

charges non-members of that organization for copies of the implementation guide.

(CMS, 2010)

Accounts Payable

Development, approval, and publication of the medical office operations

budget should be an annual event that controls disbursements and expenditures

for equipment, salaries, services, and supplies for the practice. Every department

in the medical office is important. The accounts payable department is essential to

the business relationship that allows the health care services provided to

continue in an uninterrupted manner.

Purchasing And Stores

The preferred vendor list is prepared as a function of the medical office

operations budget development and approval process.

Request for purchases must be approved by the management staff person

31
responsible for adherence to budgetary disbursements. Upon reception of

supplies and equipment or the initiation of services, the purchasing and stores

department – if separate departments – will notify, with documentation.

(e.g. purchase request, contracts, etc.) the accounts payable department of

the arrival of the approved items into the facility. If this activity is conducted by

electronic protocol the accounts payable department will record the status of the

account accordingly.

Medical Records

The patient’s first visit to the medical office begins a litany of services

and activities that document the clinical services received and the clinical

progress or lack of progress achieved at the hands of the physician and staff.

Historically, the patient medical record has been documented on hard copy paper

and filed alphabetically pending retrieval when the need is required. Electronic

Medical Records (EMR) have rendered hard copy paper medical records archaic,

expensive, inefficient and loss prone.

There is no documented evidence to support the number of medical charts

that have been misfiled, misplaced or completely lost. However, experience has

shown that this type of incident is the most prevalent faux pas committed by

errant medical office staff. It should be the responsibility of the medical office

management to take advantage of the advent of available information technology

and the implementation of electronic medical records. (EMR) If a returning

patient to the medical office is confronted with a situation caused by a missing

32
medical chart, the time and expense associated with the absence of the patients’

medical history and the delay and/or continuation of care can be detrimental to the

patients’ ongoing plan of care. If the aggrieved patient should bring suit against a

medical practitioner charging medical malpractice, using any of the

aforementioned examples as a charge and, if at trial, the patients’ case is

upheld, the physicians’ medical liability insurance premium could be increased

accordingly. Depending upon the severity of the charges, it could put the medical

license of the medical office owner and the medical practice could be at risk.

In the study, Missing Clinical Information During Primary Care Visits, (Smith,

M.D., Peter C., et.al., 2005) the investigators report that primary care physicians

encounter situations where missing clinical information is common, multifaceted,

likely to consume time and other resources, and may adversely affect patients.

There are multiple ramifications associated with the situation of missing charts.

Lost Patient Medical Chart:

▪ Missing clinical reports from previous diagnostic procedures

▪ Reports of missing clinical information from referring physicians

▪ Medicinal prescription(s) data re: indication, frequency, type, use

▪ Applicable familial history associated with patients’ diagnosis

▪ Delays in patient plan of care

▪ Likelihood of adverse effects caused by delays

▪ Time expended in search of missing patient data

▪ Time expended in their recapturing of patient data

33
All of the above items are affected by inefficient non-clinical activities in the

ambulatory environment.

The industry of medicine is multi-faceted in the sense that the large number of

medical specialties and sub-specialties are serviced by practitioners at all levels of

care and expertise. There is documentary evidence to support numerous reports of

physician error, some of which are avoidable and others which are un-avoidable.

(Millenson, M., 2006 and Chassin, M.R., 1998)

The Institute Of Medicine in its deliberations between 1996 and 1998 reported

similar situations in primary care medical offices. (IOM, 1998) Monitoring the

clinical and non-clinical operations of national medical offices would have the

positive effect of decreasing the potential for poor health care delivery and

abating the increasing cost of health care in America. Workflow is the manner by

which the medical office conducts its daily business. Electronic tools like EMR

devices can help to simplify workflow and improve patient care. Sometimes,

decisions that affect workflow are made in the interest of ease, time or staffing

concerns but do not adhere to best practices for patient care. It is the physician’s

responsibility to maintain oversight when studying workflow in the organization.

(Health Information and Management Systems Society, HIMSS, 2007)

The medical office does not become paperless over-night. It is a process that takes

time. Make sure the physician has goals that are realistic. Many medical offices

choose to aim for “paper light” status and move toward “paperless” gradually.

It is wise to phase in changes over time. The medical in-office staff will certainly

feel – and probably will be – less productive at first.
34
Be patient and give everyone time to adjust. Do what you need to do to achieve

the “go live” status. Don’t worry about leaving some tasks for phase two. Tasks

such as connecting multiple clinical laboratory interfaces or designing patient

portals can be implemented six months to a year after your medical office is ready

to go live. (HIMSS, 2007)

Environmental Services

There are some areas of the medical office that must, of necessity, be

sterile at all times. There are other areas of the office environment that must be

clean and orderly at all times. It is the Department of Environmental Services that

is responsible for the maintenance of the health care delivery facility. The care

and safety of the patients who present themselves for services need not be

concerned about the probability of being exposed to an unclean or contaminated

environment. The entire employee staff of the medical office are collectively

responsible for the safe condition of their work place and must, at all times,

present positive actions to maintain a safe and orderly environment for everyone.

35
Chapter 4 : Medical Office Compliance Certification System
Development Implementation

There are multiple reasons or purposes for the medical office audit system.

all are important, all are needed and all can be implemented with the support of

federal and private insurance carriers of the nation. By becoming actively

involved in the improvement of the delivery of quality health care, patients

visiting the American private medical offices will experience positive clinical and

non-clinical out-comes. By doing so, the services rendered will reduce existing

and potential physician errors, missed diagnosis, misinterpreted medicinal

prescriptions, reduce cost and prevent the lost or misplaced medical records. The

collective accumulation of these items will improve the delivery of services to the

patients and thus improve their quality of life.

The Center For Medical Office Compliance Certification (CMOCC) is a proposed

agency that would be the authority for conducting regularly scheduled

compliance audits -- every five years -- to determine a level of

professional competence to provide quality health care services to the public. This

auditing program would apply to all private medical offices operated by licensed

physicians in the United States. The Institute of Medicine (IOM), Quality of

Health Care In America Committee was formed in June, 1998 to develop a

strategy that will result in a threshold improvement in quality during the following

ten years. The committee believes that although there is still much to learn about

the types of errors committed in health care and why they occur, enough is known

today to recognize that a serious concern exists for patients.

36
Whether a person is sick or just trying to stay healthy, they should not have to

worry about being harmed by the health system itself. (Ancient Medicine, 1997)

The committee recommends (Recommendation 4.1) that the United States

Congress should create a Center for Patient Safety within the Agency for

Healthcare Research and Quality (AHRQ).

One of the positive components of the medical office audit system is the

opportunity for the practitioner owner to gather information about the practice

that is not immediately obvious. It is not the singular purpose of the audit to be

punitive. An audited medical office found to be delivering sub par health care

would have the opportunity to correct any such situation. The system is designed

to support the non-clinical operations of the practice and to provide a safe

environment for the consumer patients. A by-product of the proposed system is to

reduce the delivery cost of patient services and to increase the efficiency of the

total facility operation.

37
Sub-Chapter Four - Scope Of The Audit System

The states included in a designated region are configured in groups

geographically according to their proximity to one another.

United States Of America Regional Definitions And Geographical Areas

Regional
Assignment
Regional
Population
Number Of
Regional
Counties
Number Of
Regional Cities
Geographical
Area
I 22,843,876 86 1,072 Northeast
II 45,831,684 242 487 Eastern Seaboard
III 47,888,603 308 1,073 Mid-East
IV 41,729,302 321 1,275 South
V 40,755,121 369 2,077 Upper Mid-West
VI 31,530,985 371 1,744 Mid-West
VII 11,561,964 127 325 Northwest
VIII 52,646,277 157 1,150 West And Far
West
TOTALS 294,787,809 1,612 9.203 USA

The Regional Director will appoint one State Supervisor for each state within the

designated region. It is the state Supervisor that has the managerial responsibility

for the state medical offices compliance auditors.

It is the compliance auditors who provide the MOCC Center / Medical Office

interface. The individual auditor executes the compliance protocol as mandated

by the Center. The directorial staff of the Center supports the efforts and activities

of the auditors. The variable quantity of licensed auditors within each state will be

determined by the number of medical offices that request a facility compliance

certification audit.

38
The following are the Compliance Certification Geographical Regions and their

associated states:

▪ Region – I Connecticut, Maine, Massachusetts,
New Hampshire, New Jersey, Rhode Island,
Vermont

▪ Region – II Delaware, District Of Columbia, Maryland,
New York, Pennsylvania

▪ Region – III Indiana, Kentucky, Michigan, North
Carolina, Ohio, Tennessee, West Virginia

▪ Region – IV Alabama, Florida, Georgia, Louisiana,
Mississippi, Puerto Rica, South Carolina

▪ Region – V Arkansas, Illinois, Iowa, Minnesota,
Missouri, Wisconsin

▪ Region – VI Kansas, Montana, Nebraska, North Dakota,
Oklahoma, South Dakota, Texas

▪ Region – VII Colorado, Idaho, Montana, New Mexico,
Utah, Wyoming

▪ Region – VIII Alaska, Arizona, California, Guam, Hawaii,
Neveda, Oregon, Washington

Medical Office Audit

The business and logistic components of the American medical offices

have never had an audit to evaluate their non-clinical operations protocol to

regulate its operations protocol. The clinical operation of the medical practice is

not the only component of the medical office that affects the quality of care for

the patient. Non-clinical activities of the medical office, if in-effective, can have

a negative effect on the patients’ clinical outcomes if not properly controlled.

When addressing the total activities of the medical office there is an opportunity

39
for improvement of the positive outcomes for the patients clinical well-being. The

performance of a regularly scheduled medical office audit allows the medical

practice to monitor all aspects of the non-clinical components of the medical

office system.

The proposed auditing protocol combined with regularly scheduled staff

meetings will allow appropriate adjustments to existing policies and

procedures. This set of improvements will also afford the medical office

the opportunity to correct any errors or add any procedures that could have

a positive impact on the practice.

Medical Office Compliance Audit Instrument
The purpose of the medical office compliance audit is to demonstrate to
the consumer public that the medical services provided in this facility are of the
highest quality and proficiency as found by an independent auditing agency. A
licensed auditor must be a trained health care professionals with an expertise

that is medical office compliance surveillance.

The presence of compliance auditor(s) in the medical office is by the invitation of
the Medical Director or Physician Owner. The person who holds this position has
made application to the auditing agency confirming the invitation. The integrity of
the auditor findings is accurately documented in a manner that is honest, equitable
and without malice.
The document that contains the audit results is the audit valuation report.
Medical Office Audit Charges

The medical office will extend an invitation to the Center in the form of a

40
CMOCC application (Exhibit No. 01) to participate in a Medical Office

Certification Audit. The application is accompanied by the payment of an audit

charge (one office) based upon the following example formula:

▪ Two ($2.00) dollars per patient (pts) visit of the previous year, plus

▪ Twenty-five ($0.25) cents per on site laboratory diagnostic procedure
(ldxp) of previous year, plus

▪ Fifty ($0.50) cents per on-site diagnostic radiologic procedures (rdxp) of
previous year, plus

▪ Six hundred ($600.00) dollars CMOCC Center (cac) (one office) Audit
charge

Calculation Example: (one medical office)

▪ 25 pts / 5d wk. / 52 wk. yr. = 6,500 pts / yr
▪ 75 ldxp / 5d wk. / 52 wk. yr = 19,500 ldxp / yr.
▪ 15 rdxp / 5d wk. / 52 wk.yr. = 3, 900 rdxp / yr.
▪ 6,500 pts / $2.00 csc = $13,000.00
▪ 19,500 ldxp / $.25 csc = $ 4,875.00
▪ 3,900 rdxp/ $.50 csc = $ 1,950.00
▪ CMOCC Audit Charge = $ 600.00

Medical Office Audit Charge = $ 20,425.00

The total CMOCC medical office audit charge will vary according to variables

associated with the number of patient visits and the number of diagnostic

procedures. The Center audit charge is the same regardless of the variables. It is

highly unlikely that all of the existing medical offices would be audited in the first

five years of operation. It is reasonable to expect that CMOCC would be fully

operational – all states – in ten years. Using the aforementioned example to

generate revenue in the amount of $14.9 billion dollars ($14,933,557,925.)

for all 753,269 medical offices audited 753,269. (Exhibit 08)

41
The audit charges are not recoverable from any source except as an internal

revenue tax deductible business expense.

The Importance Of A Medical Office Audit System

The development of a medical office audit system serves multiple

purposes. It will provide :

▪ Standardization of medical office non-clinical operating policies
and procedures

▪ Regularly scheduled visitation to medical office policy and
procedures for changes and/or adjustments

▪ Monitoring and standardization of medical office technology systems

▪ Monitoring and adherence to federal policy associated with Health
Insurance Portability and Accountability Act (HIPAA)

▪ Medical office management tool for implementation of new business
procedures and/or vendor providers

▪ Public notification to medical office patients that the services rendered in
this facility has been audited and had received a status of certification to
provide quality medical care to the public

▪ An inspected repository of current professional credentials that
apply to professional employees, i.e. licensure, certification, etc.

▪ An inspected repository of current professional credentials of
professional employees who provide diagnostic procedures for medical
office patients

Staffing Structure of The Center For Medical Office Compliance
Certification

The CMOCC professional staff would be comprised of :

▪ Center Director
▪ Associate Director
▪ Compliance Auditor
▪ Audit Review Supervisor
▪ Regional Director (1)
42
▪ Center Support Staff
▪ Regional Supervisors (8)
▪ Licensed Medical Office Compliance Auditors
(adequate to satisfy regional medical office volume) (Exhibit 8)

The Medical Office Compliance Certification System (MOCC) calls for

the use of trained and licensed professionals with a job title, Medical

Office Compliance Auditor. Currently the United States Department of

Labor has no listing for the job description of a Medical Office Compliance

Auditor.

Auditor, Training and Licensure

Auditors of the Compliance Certification Center will be selected from the

ranks of experienced health care professionals who are able to provide medical

office audit activities. Already trained in various disciplines of health care

delivery, these professionals must be further trained to perform the specifics

associated with the compliance audit of private medical offices. After the course

of training is completed, the auditors will challenge a state sponsored license

examination. It is the trained and state licensed auditor who will conduct the

medical office audit on behalf of the Center For Compliance Certification. The

auditor is required to participate in an approved program of continuing education

to maintain licensure, e.g. every two –three years.

Auditor Instructor Training Manual

Medical offices, urgent care facilities, and emergency rooms serve as the first line

of defense for health care delivery. Emergency rooms are generally operated in an

environment that is controlled by an acute care facility that is responsible for the

43
standards of professional medical care performance.

Private medical offices and urgent care facilities are privately owned and

are operated as a business, controlled and regulated by a physician, physician

group or health plan. It is the responsibility of a clinical practitioner to provide

and environment of safety and confidence for patients who present themselves for

health care services. Too often, private medical offices are found to be providing

sub-standard medical care. (Millenson, M., 11-0806)

Private medical offices in America are not audited to determine a level of

compliance for the provision of quality health care services to the public.

It will be the responsibility of an outside agency – CMOCC -- to provide

regularly scheduled monitoring surveillance and to determine the level of

professional competence and certification of the medical office. Currently,

there is no outside agency that provides compliance auditing for private

medical offices as related to non-clinical operational performance.

To accomplish this task, the auditing agency must provide individuals or

teams of professionally trained auditors to determine compliance and

certification of the medical office. It is the purpose of this training program to

serve as a guide in the training of students to be Licensed Medical Office

Auditors.

Use Of The Auditor Instructors Training Manual

The training program for medical office auditors -- Instructors Manual –

is written for the express use of the course instructors and may not be

reproduced in any form without the formal written permission of the
44
director of the Center for Medical Office Compliance Certification who

holds authority and responsibility for the course. This document is not to

be shared with students for any reason. The material content of this manual is

uniquely specific to the subject matter of health care delivery in the private

medical office. The instructor may not vary in the presentation of the information

contained in this manual. To do so constitutes a severe conflict of interest and is

considered to be fraudulent. Personal opinions, religious affiliations or political

influence have no place in the presentation of the course. During the training

period, the student is expected to attend scheduled course classes, participate in

class activities, submit class assignments upon request, and finally evaluate the

instructor of the course. The student must receive a passing grade “ B “ in the

course to qualify as an applicant for licensure in their state of residency. The

specific goal of the course is to prepare the student to become a Licensed Medical

Office Auditor.

To accomplish this, the student must successfully challenge and pass a national

licensure examination.

By extending an invitation to the agency, the medical director or owner

physician understands the purpose for the audit, the benefits of a successful audit

and the consequences of an unsuccessful audit. The cooperation of federal or

private insurance carriers that are supporters of compliance sanctions is crucial to

the effectiveness of the compliance program.

45
If an insurance carrier elects to withhold claims payment because of non-

compliance, it notifies the offending medical office of the decision with

copies to the auditing agency regarding the extent and duration of the

penalty. Such an action requires an appropriate corrective action plan from

the non-compliant medical office for scheduling a re-audit. There is no

fee attached to an agency approved corrective action plan authorizing a re-

scheduled audit.

The auditor or team(s) is/are equipped with an Audit Valuation Work Sheet

(Exhibit 02) which is used to document its findings. Each item audited is

assigned an Audit Value.(AV) All items audited are assigned, do not have an

equal audit value. The valuation assigned is pre-determined and can be

greater or lesser, depending upon the importance of the item to the

proficiency and efficiency of the delivery system.

Documentation of Medical Office Audit Findings

Documentation of the findings in the medical office compliance certification audit

are extremely important not only to the owner of the practice and staff but also

to the patient clients as well. Client assurance, trust and comfort in the providers

of clinical and non-clinical services, give the patient and the patient’s family

confidence in everyone associated with the level of care services performed.

When the owner of the medical office demonstrates to the public that the

services offered at the medical office are above reproach, the invitation to be

audited is an act of confidence that is worthy of note.

46
The staff that provides interface and non-clinical support with the public

on behalf of the clinical practitioners are directly involved in their provision of

care. The auditors of the Center for Compliance Certification are trained

healthcare professionals that have the experience to conduct the medical office

audit with efficiency and integrity. By doing so, the conduction of the audit

provides the provider owner with the services of an independent agency that can

verify the quality of health care delivery to the facility. It further demonstrates to

the public and supports the desire of the medical office to be as current as

possible in the delivery process. During the audit process, the auditors will declare

the presence or absence of services and activities that indicate the provision of

non-clinical quality medical services in the facility. (Exhibit 02)

The audit instrument is designed in such a way that the audited finding

cannot be misinterpreted by the auditor or the attendant staff representative of the

medical office. All aspects of the non-clinical aspects of the medical practice are

the focus of the audit.

The audit items are rated from ten (10) to one (1). If a system is without an

item, or process, the documentation is No = 1. If an item is

present or a system is in place, Yes = (10). If partial, the auditor rating

would be somewhere between (9-2). The judgment of the auditor is not

arbitrary. The auditor’s professional decision will be based upon the on-site

findings and relevant discussion(s) with the attendant staff person. The

findings will ultimately be decided by the CMOCC Audit Supervisor.

47
Justification For A Medical Office Audit System

The North Shore Hospital System in Long Island, New York recently

announced that it will pay an incentive of up to $40,000 to each physician

in its network who adopts its electronic health record (EHR) program –

paying 50% of the cost if the physician also shares de-identified data on

the quality of care. This payment would apparently come on top of the

$44,000 incentive that the American Recovery and Reinvestment Act of

2009 (ARRA) has authorized Medicare to pay each eligible health care

professional who uses certified EHRs in a meaningful manner. “ Meaningful

Use” is still being defined, but the overarching goal is to improve the population’s

health through a transformed health care delivery system with the use of EHRs to

improve local processes, foster quality measurement, and increase

communication. (Shea, M.D., Steven and Hripcsak, M.D., George. Jan. 2010)

Wide dissemination of EHRs requires public trust. The sharing of patients’

information – which has been common practice for decades for the purposes of

billing, treatment, and public health – has come into the public eye because of the

risks associated with vastly expanded sharing and new found ability to easily and

quickly transfer many patient records simultaneously. The Health Insurance

Portability and Accountability Act of 1996 (HIPAA) created a framework for

defining privacy, breaches of privacy, and penalties.

The HIPAA further defined privacy breaches and increased the penalties for them.

One of the challenges to setting policy in this area is that electronic privacy and

48
its relative importance are still being defined. The capability of providing a secure

electronic environment for patient data – like the capability of providing reliable

data storage – is beyond the reach of most individual physician practices.

(DesRoches, D.P.H., C.M., Campbell, Ph.D., Eric G., Sowmya, Ph.D., Rao, et.al.

2009)

Operational activities that occur in the private medical office can have an effect

that might cause negative ramifications throughout the health care delivery

system. If a hand written medication prescription is misinterpreted at a dispensing

pharmacy because of misspelled or poorly written words or abbreviations, it could

cause difficulties, impairment or even death to a patient. If a patient is admitted to

a general hospital facility with a missed diagnosis, the additional expense

associated with an extended length of stay could negatively impact the patient’s

health insurance. If all current plans to start new programs are realized, nearly

eighty-five percent of all states will be operating Medicaid Pay-for-performance

programs. (Ancient Medicine, 1997)

Medical practitioners are obligated to their profession to provide, to the best of

their abilities, services that can best satisfy the maladies of their patients…..at all

times.

The implementation of improvement efforts at any level of the health care

delivery process is a necessary beginning. Newly

developed systems that are collectively coordinated will have a positive impact

upon national health care delivery as they impact the quality of clinical outcomes,

49
patient satisfaction, compliance certification, and accountability to organizational

health plans. The Medical Office Compliance Certification Audit System

Implementation is a contribution to that improvement effort.

50
Glossary

Fee-For-Service - Medical fee amount paid for a specific service
rendered

Managed Care. - Physician members of Health Maintenance
Organizations (HMO) that provide medical
services to HMO patients

Purchasing. - Buying, Obtaining, Procuring.
Stores. - To put or hold something somewhere for safe
keeping (e.g. storage room)

Tort. - Unlawful act, Offence, Wrongdoing, Illegal act

51
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IMPROVEMENT OF HEALTH CARE DELIVERY IN AMERICA :
Medical Office Compliance Certification System Development
Implementation

CENTER FOR MEDICAL OFFICE COMPLIANCE CERTIFICATION
AUDIT APPLICATION

Exhibit Number 01

This Medical Office Last Audit Date____________________ Last Auditor name _____________

Last Auditor I.D. Number ____________________ Last Auditor Region / Number ____________

MEDICAL OFFICE INFORMATION (Please type or print all requested information. If
information does not apply, insert “NA”)

Medical Office Name _____________________________________________________________

Main Voice Telephone No. ________________ Emergency Coverage Voice Telephone No. ____

Date(s) at this location _________- __________ Dates(s) at previous location _________ - _____

Physician Owner Name ___________________________________________________________

Medical Office Practice Location Address ____________________________________________

City / State / Postal Code __________________________________________________________

Medical Office Mailing Address ____________________________________________________

City / State / Postal Code __________________________________________________________

Medical Office Administrator or Office Manager Name __________________________________

Direct Telephone No. and/or Ext. No. ________________________________________________

Is there a current (original) set of medical (non-clinical) office operations Policy & Procedure
Manuals in the office of the Medical Director or Physician owner ? □ Yes □ No
Each Policy & Procedure Manual is authorized (by signature )_______________________M.D.
Medical Director or Physician Owner
Date_______________

Each Policy & Procedure Manual is signed (acknowledged) by each respective department head .
□ Yes □ No
Supervisor Name, Clinical Laboratory ________________________________________________
Supervisor Name, Environmental Services ____________________________________________

Page 1 of 15
CMOCC AUDIT APPLICATION Page 2 of 15
Supervisor Name, Human Resources _________________________________________________
Supervisor Name, Nursing Service __________________________________________________
Supervisor Name, Purchasing and Stores _____________________________________________
Supervisor Name, Radiology ______________________________________________________
Supervisor Name, Business Office __________________________________________________
Supervisor Name, Facility Security _________________________________________________
Supervisor Name, Medical Records _________________________________________________
Legal Counsel Name _____________________________________________________________
Legal Counsel Direct Contact Telephone Number_______________________________________
Legal Counsel Company Name _____________________________________________________
Legal Counsel Company Location Address ____________________________________________
Suite No. ___________ City / State / Postal Code ______________________________________
Legal Counsel Company Telephone Number __________________________________________
Legal Counsel Company Electronic Mail Address ______________________________________
Medical Office Facility Liability Insurance Carrier Name _______________________________
Medical Office Facility Liability Insurance Policy Number ______________________________
Medical Office Facility Liability Insurance Policy Current Effective Date ___________________
Medical Office Facility Liability Insurance Carrier, Agent name __________________________
Medical Office Facility Liability Insurance Carrier Local Main Telephone Number ___________
Medical Office Facility Liability Insurance Carrier Local Location Address _________________
Suite No. __________City / State / Postal Code ________________________________________
Medical Practice Liability Insurance Carrier Name _____________________________________
Medical Practice Liability Insurance Carrier Main Local Telephone Number ________________
Medical Practice Liability Insurance Carrier Local Location Address ______________________
Suite No. __________ City / State / Postal Code _______________________________________
Medical Practice Liability Insurance Carrier, Agent Name ______________________________
Medical Practice Liability Insurance Carrier, Agent State License Number __________________

CMOCC AUDIT APPLICATION Page 3 of 15
Medical Practice Liability Insurance Carrier, Agent State License Effective Date _____________
Medical Practice Liability Insurance Carrier, Agent Cellular Telephone No. _________________
Medical Practice Liability Insurance Carrier, Policy Number _____________________________
Medical Practice Liability Insurance Carrier, Current Effective Date _______________________
Municipal Business License of City _____________________________ State ________________
Municipal Business License Publicly Displayed □ Yes □ No
Municipal Business License Number ______________________ Effective Date ______________
Medical Office Operational days per previous year _______________
Number of Patient visits per previous year. Year _________ Patient Visits ____________
Total floor space of entire medical office ________________sq. ft. Consultation Room(s)
________sq. ft.
Number of Clinical Examination Room(s) __________ Floor Space: Clinical Exam.
Room(s)______sq. ft.
Floor Space: Secure Medical Records ________sq. ft. Secure /
Fire proof Storage for Electronic Data Records
Floor Space: Secure Medical Billing Records ____________ sq. ft. Patient Reception area
________sq. ft.
Floor Space: Physical Therapy ____________ sq. ft. Secure Human Resources Records
_________ sq. ft.
Floor Space: Medical Business Office _____________ sq. ft. Facility Maintenance Storage
________sq. ft.
Floor Space: Medical Office Supplies / Equipment Storage ________________ sq. ft.
Floor Space: Sterile Central Supply ______________ sq. ft. Non-Sterile Central Supply
__________ sq. ft.
Floor Space: Secure Pharmaceutical Storage ____________ sq. ft. Physician Owner Office
________sq. ft.
Floor Space: Clinical Diagnostic Laboratory ________ sq. ft. Clinical Diagnostic Radiology
_______sq. ft.
Method of bio-hazard waste disposal ________________________________________________
Method Of Equipment Sterilization __________________________________________________
Method of clinical examination room maintenance ____________________________________

CMOCC AUDIT APPLICATION Page 4 of 15
Medical Office Facility : □ Own □ Lease
If Medical Office is leased, What is the renewal lease period ? ___________________________
Generally, patients that come to this medical office, have their medicinal prescriptions filled at:
____________________________________________________________________Pharmacy
MEDICAL PRACTICE INFORMATION (Please provide one set of data for each licensed
physician practicing in this medical office)

Physician Owner / Medical Director Name ____________________________________________

Medical Specialty ______________________________________Sub-Specialty______________

Medical School Attended__________________________________________________________

Date Attended _____________________________ Date Graduated ________________________

Is there hard copy evidence of this degree in the records of this office ? □ Yes □ No

If No, Please attach and send hard copy evidence of the earned degree at the time this
application is submitted.

Facility name where this applicant completed a medical specialty residency _________________

Dates Attended _________________________________ City/State/ Postal Code _____________
Is there hard copy evidence of the completed a medical specialty residency □ Yes □ No

If No, Please attach and send the hard copy evidence of the completed medical specialty
residency at the time this application is submitted.

Facility name where this applicant completed a clinical fellowship _________________________

Dates Attended ________________________ City / State / Postal Code _____________________

Is there hard copy evidence of this clinical fellowship in the records of this office ? □ Yes □ No

If No, Please attach and send hard copy evidence of the completed clinical fellowship at the time
this application is submitted.

Granting Agency of the applicant to practice medicine __________________________________

Medical License Number ___________________ Effective Date ______________ State _______

Medical Liability Insurance Carrier__________________________________________________

Medical Liability Insurance Carrier Policy No. ___________________Effective Date __________

REGISTERED NURSE ( Please provide one set of data for each Registered Nurse in this office)

CMOCC AUDIT APPLICATION Page 5 of 15

Registered Nurse Name ___________________________________________________________

School where Registered Nurse earned degree _________________________________________

City / State / Postal Code __________________________________________________________

Dates of attendance ________________________________ Date Graduated _________________

Type of Degree : □ R.N. □ B.S.N. □ M.S.N. □ C.N.P.

Registered Nurse License Number _________________________ Effective Date _____________

Is there hard copy evidence of this Nurse License in the records of this office ? □ Yes □ No

If No, Please attach and send hard copy evidence of this Nurse at the time this application is
submitted.

Medical Liability Insurance Carrier __________________________________________________

Medical Liability Insurance Carrier Address ___________________________________________

City / State / Postal Code __________________________________________________________

Medical Liability Insurance Policy Number ___________________ Effective Date ____________

Medical Liability Insurance Agent name ______________________________________________

Number Of Registered Nurse(s) employed in this office ____________________

CERTIFIED NURSE PRACTITIONER (Please provide one set of data for each CNP in this
office)

Certified Nurse Practitioner Name ___________________________________________________

School attended where Nurse Practitioner earned practice License __________________________

Dates Of Attendance ______________________________ Date Graduated __________________

City / State / Postal Code ___________________________School Telephone No. _____________

Certified Nurse Practitioner License No. ______________ Effective Date ___________________

Is there hard copy evidence of this Certified Nurse Practitioner License in this office ?□ Y □ N

If No, Please attach and send hard copy evidence of this Nurse Practitioner License at the time

this application is submitted. CNP Medical Liability Insurance Carrier Name
______________________________________________________________________________

CNP Medical Liability Insurance Carrier Address ______________________________________

CMOCC AUDIT APPLICATION Page 6 of 15

City / State / Postal Code __________________________________________________________

CNP Medical Liability Insurance Policy Number ______________Effective Date _____________

CNP Medical Liability Insurance Agent Name ________________Direct Telephone No. _______

Number of Certified Nurse Practitioners in this office _______________

PHYSICIANS ASSISTANT (Please provide one set of data for each PA in this office)

Physicians Assistant Name _________________________________________________________

School attended where Physicians Assistant earned practice license ________________________

City / State / Postal Code __________________________________________________________

Dates of attendance________________________ Date Graduated _________________________

Physicians Assistant License No. ___________________ Effective Date ____________________

Is there hard copy evidence of this Physicians Assistant License in the records of this office ?
□ Yes □ No
If No, Please attach and send hard copy evidence of the Physicians Assistant License at the

time this application is submitted.

PA Medical Liability Insurance Carrier _______________________________________________

PA Medical Liability Insurance Carrier Address ________________________________________

City / State / Postal Code __________________________________________________________

PA Medical Liability Insurance Policy No. ____________________ Effective ________________

PA Medical Liability Insurance Carrier Agent Name ____________________________________

Number of PA’s in this office ________________________

REGISTERED MEDICAL TECHNOLOGIST (Please provide one set of data for each RMT
in this office)

Registered Medical Technologist Name ______________________________________________

School attended where Registered Medical Technologist earned License
______________________________________________________________________________

City / State / Postal Code _______________________ School Phone No. ____________________

Registered Medical Technologist License No. ____________ Effective Date _________________

CMOCC AUDIT APPLICATION Page 7 of 15

Is there hard copy evidence of the RMT License in the records of this office ?
□ Yes □ No

If No, Please attach and send hard copy evidence of this Registered Medical Technologist License
at the time this application is submitted

Number of RMT’s in this office _______________________

REGISTERED RADIOLOGY TECHNOLOGIST (Please provide one set of data for each
RRT in this office)

Registered Radiology Technologist Name ____________________________________________

School attended where Registered Radiology Technologist earned License
_______________________________________________________________________________

City / State / Postal Code ____________________________ School Phone No. _______________

Registered Radiology Technologist License No. ___________ Effective Date ________________

Is there hard copy evidence of the RRT License in the records of this office ? □ Yes □ No

If No, Please attach and send hard copy evidence of this Registered Radiology Technologist
License at the time this application is submitted

Number of RRT’s in this office _______________________

REGISTERED PHYSICAL THERAPIST (Please provide one set of data for each RPT in this
office)

Registered Physical Therapist Name _________________________________________________

School attended where Registered Physical Therapist earned License
_______________________________________________________________________________

City / State / Postal Code _________________________School Phone No. __________________

Registered Physical Therapist License No. ________________ Effective Date ________________

Is there hard copy evidence of the RPT License in the records of this office ? □ Yes □ No

If No, Please attach and send hard copy evidence of this Registered Physical Therapist License at
the time this application is submitted

Number of RPT’s in this office _______________________

CMOCC AUDIT APPLICATION Page 8 of 15

MEDICAL OFFICE, BUSINESS OFFICE

Business Office Supervisor Name ___________________________________________________

Business Office operations are: □ Computerized □ Manual □ Both

Is there a current authorized copy of the departmental operations Policy and Procedure Manual
in the department ? : □ Yes □ No

If Yes, have all staff read with understanding the contents of the departmental Policy and
Procedure
Manual ? □ Yes □ No

Business Office Policy and Procedure Manual is signed by _______________________________

Medical Director or Physician owner

Business Office Policy and Procedure Manual is signed by _______________________ Business

Office Department Head
Does the Medical Office accept □ cash □ credit cards □ personal checks □

health plan card for services rendered ? (Check all that apply)

If Yes, what is the method of accounting ? ____________________________________________

Does the medical office accept checks from insurance carriers with explanation of benefits ?
□ Yes □ No

If Yes, What is the method of accounting ? ___________________________________________

How does the business office receive patient billing charges information ? ___________________

_______________________________________________________________________________

How are the payments for services rendered applied to patient accounts ? ____________________

_______________________________________________________________________________

Does the Explanation Of Benefits show the patients name and identification number ?
□ Yes □ No

If No, Explain __________________________________________________________________

_______________________________________________________________________________

CMOCC AUDIT APPLICATION Page 9 of 15

How are the Statement Of Benefits filed ? _____________________________________________

Name of the Medical Office Banking Institution ________________________________________

Account Name _________________________________ Account Number __________________

What type of deposits are made to this account ? _______________________________________

Who is the person (Title) that makes deposits to this account ? ____________________________
Does this account require more than one signature for disbursement ? □ Yes □ No
Does this account require more than one signature for disbursement ? □ Yes □ No

If Yes, Explain __________________________________________________________________

If Yes, Explain __________________________________________________________________

_______________________________________________________________________________

Who is the authorized disbursement (1) signer to this account? __________________ Title _____

Who is the authorized disbursement (2) signer to this account? __________________Title ______

What is the process by which disbursements are authorized ? _____________________________

_______________________________________________________________________________

Is there a purchase request system in operation in the medical office ? Explain ________________

_______________________________________________________________________________

Is there a purchase order system in the medical office ? Explain ___________________________

_______________________________________________________________________________

Is there a petty cash system in operation in the medical office ? Explain _____________________

_______________________________________________________________________________

What is the vendor payment schedule ? ______________________________________________

How does the business office receive employee payroll information from the human resources
department ?

_______________________________________________________________________________

How does the business office receive notification of payroll changes ? ______________________

_______________________________________________________________________________

CMOCC AUDIT APPLICATION Page 10 of 15

What is the employee payroll payment period ? ________________________________________

PATIENT MEDICAL RECORDS

Medical Records Library Supervisor Name ____________________________________________

Are Electronic Medical Records in operation in this medical office ? □ Yes □ No

If No, Why not ? ________________________________________________________________

_______________________________________________________________________________

Is there a current authorized copy of the departmental Policy & Procedure Manual in the
department ? □ Yes □ No

If Yes, have all departmental staff read to understanding the Policy & Procedure Manual ?
□ Yes □ No
If No, Explain __________________________________________________________________

Policy & Procedure Manual signed by ______________________________, Medical Director or
Physician owner

Policy & procedure Manual signed by _______________________, Medical Records Library
Depart. Head

How often is the Medical Records Library Un-attended ? _________________________________

Describe the Medical Office, Medical Records Library Security System _____________________

_______________________________________________________________________________

Who from the medical office staff (title) __________________ can retrieve (un-attended) a patient

medical record ?

Who from the medical office staff (title) __________________ can retrieve (un-attended) a patient

medical record ?

Who from the medical office staff (title) __________________ can retrieve (un-attended) a patient

medical record ?

Who from the medical office staff (title) __________________ can retrieve (un-attended) a patient

medical record ?

What is the annual average number of medical records stored in the medical records library ?

__________
CMOCC AUDIT APPLICATION Page 11 of 15

How often does the department conduct an active medical records audit ? ___________________

How are the results of the active medical records audit logged ? ___________________________

What is the schedule of the medical records audit corrective action plan ? ____________________

What is the number of medical office staff assigned to the medical records library ? ___________

How is a patient medical record returned to the medical records library ? ____________________

_______________________________________________________________________________

What is the method of active and in-active medical records storage ? _______________________

When received into the department, is the patient medical record date and time stamped ?
□ Yes □ No
Does the Medical Records department accept an un-signed patient medical record ?
□ Yes □ No
Medical Record log-in system is □ Manual, in log book □ Computerized by same

number or next no.
Medical Record filing system is □ Alpha, by last name, □ Numeric by assigned
number first name, middle name □ Other

If Other, Explain ________________________________________________________________

MEDICAL OFFICE HUMAN RESOURCES

Human Resources Department Supervisor Name _______________________________________

Who, from the medical office staff (title) _______________ has authorized un-attended access to

employee records?

Who, from the medical office staff (title) _______________ has authorized un-attended access to

employee records?

Is there a current authorized copy of the departmental operations Policy & Procedure Manual

in the department ? □ Yes □ No

If Yes, have all departmental staff read to understanding the Policy & Procedure Manual ?
□ Yes □ No

CMOCC AUDIT APPLICATION Page 12 of 15

If No, Explain __________________________________________________________________

How often are the human resource records un-attended or in-secure ? ______________________

What is the method of security for the human resource department ? ________________________

_______________________________________________________________________________

Are the operational activities of the human resources department ?
□ Computerized □ Manual

How many medical office staff have work assignments in the human resources department ?
_________

Do medical office staff that have work assignments in the human resources department have a
signed affidavit of confidentiality and document protection that protects the privacy of all
employees of the medical office on file ?

□ Yes □ No

If No, Explain __________________________________________________________________

How is the rate of compensation for a Licensed Physician determined ? ____________________

_______________________________________________________________________________

How is the rate of compensation for a Licensed Nurse (all classes) determined ? _____________

_______________________________________________________________________________

How is the rate of compensation for a Licensed Physician Assistant determined ?____________

_______________________________________________________________________________

How is the rate of compensation for a Licensed Medical Technologist determined ? __________

_______________________________________________________________________________

How is the rate of compensation for a Licensed Radiology Technologist determined ? _________

_______________________________________________________________________________

How is the rate of compensation for a non-clinical professional determined ? _______________

_______________________________________________________________________________

How is the rate of compensation for a non-professional, non-clinical medical office staff

determined ?____________________________________________________________________

CMOCC AUDIT APPLICATION Page 13 of 15

How is the rate of compensation for a clinical professional consultant determined ____________

_______________________________________________________________________________

How is the rate of compensation for a non-clinical professional consultant determined ? ______

_______________________________________________________________________________

What is the schedule of payment for salaried employees ? _______________________________

What is the schedule of payment for hourly employees ? ___________________________

What is the schedule of payment for clinical consultants, non employees ? __________________

What is the method of recording hours worked by hourly employees ? _____________________

_______________________________________________________________________________

What is the method of recording of scheduled worked for salaried employees ? ______________

_______________________________________________________________________________

How is the roster of compensated payments submitted to the business office ? _______________

_______________________________________________________________________________

Is the method of calculating payroll deductions □ Computerized □ Manual

Is there a position description on file for each employee of the medical office staff ?
□ Yes □ No

If No, Explain __________________________________________________________________

_______________________________________________________________________________

How often are position descriptions reviewed for necessary amendments ? __________________

Hard copy evidence is on file for all licensed medical office staff
□ Yes □ No

If No, Explain __________________________________________________________________

Hard copy evidence is on file for all medical office staff requiring medical liability insurance
□ Yes □ No

If No, Explain __________________________________________________________________

_______________________________________________________________________________

CMOCC AUDIT APPLICATION Page 14 of 15

MEDICAL OFFICE ENVIRONMENTAL SERVICES

Environmental Services Supervisor Name _____________________________________________

Is there a current authorized copy of the departmental operations Policy & Procedure Manual in
the department ?

□ Yes □ No

If No, Explain __________________________________________________________________

_______________________________________________________________________________

Policy & Procedure Manual signed by _______________________, Medical Director or
Physician Owner

Policy & Procedure Manual signed by _______________________, Environmental Services
Supervisor

Have all departmental staff read to understanding the Policy & Procedure Manual ?
□ Yes □ No

If No, Explain __________________________________________________________________

_______________________________________________________________________________

Is there a special place designated for the storage of toxic and flammable materials ?
□ Yes □ No

If No, Explain __________________________________________________________________

Is there a log used to document records of scheduled maintenance of common areas?
□ Yes □ No

If No, Explain __________________________________________________________________

_______________________________________________________________________________

Is there a log used to document records of un-scheduled maintenance of clinical areas?
□ Yes □ No

If No, Explain __________________________________________________________________

_______________________________________________________________________________

How often are the mops and absorbent materials laundered ? ______________________________

CMOCC AUDIT APPLICATION Page 15 of 15

How often are the medical office counter tops and clinical surfaces monitored and recorded for

bacterial count ? ________________________________________________________________

MEDICAL OFFICE, EXTERNAL AND INTERNAL SECURITY

The external and internal security of this medical office is provided by a Private Security Agency.

Security Agency Name ___________________________________________________________

Security Agency Local Address ____________________________________________________

Security Agency Main Telephone Numbers _____________________or ____________________

City / State / Postal Code __________________________________________________________

Medical Office Emergency Telephone Number________________ Facility Code _____________

Security Agency Representative Name / Title __________________________________________

Illegal entry (entry pass code required) into the medical office initiates a silent alarm to local
police department and Security Agency. Unauthorized breach of the medical office requires
notification to:

Medical Director or Physician Owner Name ____________________Telephone No. __________

Medical Office, Office Manager Name ______________________Telephone No. _____________

Audit Work Sheet Medical Office, Environ. Main. Supv. Name __________________ Telephone

No. ____________

CMOCC MEDICAL OFFICE AUDIT APPLICATION

Number of Medical Office patient visits for previous year _________ Assessment :

$ 2.00 per pts _______

Number of Dx Lab. Procedures for previous year _____ Assessment :

$ 0.25 per dxp ____ _____

Number of Dx Radiology Procedure for previous year _________ Assessment :

$ 0.50 per dxp _______

CMOCC Medical Office Audit Charge $ 600.00

CMOCC Submitted Audit Amount $ __________________

Mode of payment □ Check, Check No. ___________ date of check ____________

Signer __________________________________(Print name)

□ Credit / Debit Card □ American Express □ Master Card □ VISA

□ Credit/Debit Card Holder Name (print) _________________________
□ Credit/Debit Card Number ___________________________

Exp. Date ____/_____

NOTE: All payments by check or credit/debit card are made payable to Center For Medical
Office Compliance Certification. All payments are submitted with the audit application. If for any
reason submitted payment is not honored, audit application will be returned to sender.

Application Submitted By (print authorized name) _____________________________________

Application Submitted By (Authorized Signature) ____________________________________

Position Of Authority _____________________________________

Application Initial Submission Date _____________________________________

CENTER FOR MEDICAL OFFICE COMPLIANCE CERTIFICATION
Medical Office Audit Application Division
123 “E” Street, North East
Washington, D.C. 20056-1543

Main Telephone Number : 303-123-4567

1 of 1
IMPROVEMENT OF HEALTH CARE DELIVERY IN AMERICA
Medical Office Compliance Certification System Development
Implementation

Exhibit 02

MEDICAL OFFICE COMPLIANCE CERTIFICATION
AUDIT VALUATION WORKSHEET (print all data)

Audit Date ___________________ Time ____________

Auditor Name___________________________________________________________________

Auditor I.D. Number ________________ Region _______________________________________

Medical Office Name _____________________________________________________________

Medical Office Location Address ___________________________________________________

Building Name _________________________________________________ Suite No. ________

Main Telephone No. __________________________Emergency Telephone No. ______________

City / State / Postal Code __________________________________________________________

□ 1
st
Audit □ Audit Corrective Action Plan □ 2
nd
Audit □ 3
rd
Audit □ 4
th
Audit
□ 5
th
Audit

Current Compliance Status ________________________________ Audit Date _______________

Comments :
___________________________________________________________________________

_______________________________________________________________________________

MOCC Reviewer Name _________________________________________ I.D. No. __________

CMOCC Reviewer Name ________________________________________ I.D. No. __________

Medical Office Staff Audit Attendant Name ________________________________ Title ______

Medical Office Audit Closing Conference Attendee Name ________________________ Title __

Medical Office Audit Closing Conference Attendee Name ________________________ Title __

Closing Conference Comments _____________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Page 1 of 10
`Page 2 of 10

Private Medical Office Name _____________________________________________________

Medical Director Name __________________________________________________________

Medical Office Location Address __________________________________________________

______________________________________________________________________________

______________ ________________________________________________________________

Medical Office Main Telephone No. ________________________________________________

Medical Office Manager Name ____________________________________________________

CMOCC Auditor Name __________________________________________________________

CMOCC Auditor I,D, No.________________________________________________________

CMOCC Audit Date _____________________________________________________________

AV = Audit Value 1 = low – 10 = high

SECTION – I PATIENT ARRIVAL ACTIVITIES YES AV NO

1. Public display of Medical Office location identification well □ 1 □
displayed
2. Patient service waiting area is adequate, clean, and orderly □ 1 □
3. Medical Office Receptionist acknowledges patient arrival □ 1 □
immediately
4. Medical Office Receptionist initiates inquiries regarding □ 5 □
Nature of the visit
5. Medical Office Reception area adequate, well organized, l □ 1 □
functional
6. Medical Office Receptionist professionally attired for work □ 4 □
environment
7. Medical Office Receptionist invites all patients to affix their □ 3 □
names to “sign in” log

8. Medical Office Receptionist has immediate access to patient □ 3 □
medical record
9. Medical Office Receptionist explains and invites new patient □ 10 □
to prepare Patient Data Forms

Page 3 of 10

SECTION – I PATIENT ARRIVAL ACTIVITIES
YES AV NO

10. Medical Office Receptionist notifies clinical floor staff that the □ 10 □
medical record is available and the patient is ready to be seen

11. Medical Office, business department staff retrieves appropriate □ 10 □
medicaldocuments for patients being seen for medical services

12. Medical Office, clinical staff assumes escort responsibilities for the □ 10 □
movement of the patient through the various clinical areas of the
office following the physicians pre-determined plan designed for
new or returning patients .

13. Clinical staff makes the patient medical record available to the □ 10 □
Appropriate examination room and notifies the practitioner
(physician, nurse practitioner, physicians assistant) that the
patient is ready to be seen

14. The practitioner conducts any appropriate care for the patient, □ 10 □
documents the activity onto the patients medical record and
arranges for the medical record to be dispatched to the business
office for billing activities and to medical records department
for filing.

15. Medical Office environmental maintenance staff assumes □ 10 □
responsibility for preparing the examination room for the next
patient.

16. Current / Authorized Policy and Procedure manuals are available \and □ 10 □
accessible in the office of the Medical Director

SECTION – II PATIENT CLINICAL ACTIVITIES

17. Patient is escorted to clinical area where appropriate clinical staff □ 10 □
conducts procedures and documents vital signs data.

18. Patient is escorted to appropriate diagnostic department for any □ 10 □
ordered laboratory or radiology diagnostic studies.

Page 4 of 10

19. Patient is escorted to examination room for clinical assessment by □ 10 □
attending practitioner

SECTION – II PATIENT CLINICAL ACTIVITIES YES AV NO

20. Practitioner and staff attendant provide whatever medical services □ 10 □
are appropriate for the patients’ visit. Practitioner will affix a
signature to the patient medical record to validate medical care
rendered.

21. Patient medical billing information is sent to business office for □ 10 □
service(s) billing activities

22. Following billing activities, patient medical record is sent to □ 10 □
medical records department for filing

23. Current / authorized Clinical original Policy & Procedure manuals □ 10 □
are available and accessible in the office of the Medical Director

24. Current / authorized Non-Clinical original Policy & Procedure □ 10 □
are available and accessible in the office of the Medical Director

SECTION – III PATIENT MEDICAL BILLING ACTIVITIES YES AV NO

25. All medical office staff are appropriately and/or professionally □ 10 □
attired
26. All in-coming mail, carrier deliveries and parcel deliveries are □ 10 □
received, logged and signed for in the Medical Office billing
department for processing and distribution.

27. Patient billing information received in the billing office is □ 10 □
date and time stamped

28. Patient medical billing information is manually processed onto □ 5 □
forms in preparation for submission of hard copy claims payment.

29. Patient medical billing information is entered electronically via □ 10 □
data entry in preparation for electronic submission for claims payment.

5 of 10
30. Patient medical billing forms are dispatched electronically to □ 10 □
appropriate insurance carriers for claims payment.

SECTION – IV MEDICAL OFFICE ACCOUNTS YES AV NO
PAYABLE
31. Patient medical billing forms are dispatched electronically □ 10 □
claims Contractor for HIPAA editing requirements
32. Statement of Benefits are received manually with □ 5 □
Patient payment voucher, charges and benefit payments
are reconciled manually.
33. Statement of Benefits are received electronically. □ 10 □
patient charges are processed by electronic data entry
and are reconciled electronically.
34. Daily revenue received are processed for bank deposit □ 8 □
activities are reconciled manually

35. Daily revenue deposit information is processed by □ 10 □
computerized data entry are reconciled.
36. Current / Authorized copy of Policy and Procedure □ 10 □
manuals are available accessible in the Business Office.

37. Current / Authorized copy of Policy and Procedure manuals □ 10 □
available accessible in the Business Office. Business Office
staff have read to understanding the Policy & Procedure Manual.

38. Preferred Vendor list is available in medical office computer □ 6 □
system.
39. Vendor invoices are date and time stamped upon receipt into □ 9 □
the accounts payable department

40. Vendor and authorized purchase request are reconciled □ 10 □
41. Vendor invoices are processed electronically for payment □ 10 □
42. Vendor back order, balance due invoices and paid in-full □ 9 □
invoices are current in the department computerized data
entry system
43. Medical Office computerized system and all systems of □ 10 □
are audited for accuracy and results are documented in
departmental records on a monthly basis
44. Medical Office Accounts payable data and all records manual □ 10 □
and are Computerized are secured off site.
Page 6 of 10

YES AV NO
45. Current Authorized copy of Policy and Procedure manual is □ 10 □
accessible to the accounts payable staff and are read to
understanding .

SECTION – V MEDICAL OFFICE PURCHASING AND STORES

46. Purchasing and Stores department is notified of arrival to the □ 10 □
Medical office of all supplies and equipment into the facility.
47. Supplies and equipment shipping documents and authorized □ 10 □
purchase request are reconciled and are available for
computerized data entry
48. Supplies and equipment, shipping documents, purchase request □ 10 □
and authorization to pay are sent to accounts payable for
processing
49. All supplies and equipment received are checked for accuracy as □ 10 □
confirmed by Purchase Request and are in proper operational
condition
50. Supplies and equipment are distributed throughout the □ 7 □
Medical Office and the origin of the purchase request
acknowledges receipt by signature.
51. All documents in the purchasing and stores department are filed □ 7 □
52. All medicinal and pharmaceutical supplies are audited and □ 10 □
Secured appropriately in a place designed to secure all such
items and is accessible ONLY by clinical staff with authorized
access and dispensing authority. Withdrawal of these supplies
are logged by time of withdrawal, dated and signed by
authorized staff.
53. Purchasing and Stores department storage data is secured off site. □ 10 □
54. Current Authorized copy of Policy and Procedure manual is □ 10 □
accessible to the Purchasing and Stores staff and are read to
understanding.

SECTION – VI MEDICAL OFFICE, MEDICAL RECORDS

55. Medical office Medical Records are hard copy, manual □ 5 □
56. Electronic Medical Records (EMR) are operationally active □ 10 □
in this medical office
57. Medical Records operations are partially manual and partially □ 5 □
computerized

Page 7 of 10

YES AV NO
58. Medical Records department is attended or secured at all time □ 10 □
during Medical Office business hours
59. Patient Medical Records are date and time stamped when received □ 10 □
into the Medical Records department
60. Patient Medical Records are date and time stamped when □ 10 □
removed from the Medical Records department
61. All current physician orders on the patient medical record are □ 10 □
signed, time and date legible with no unacceptable abbreviations
62. Medical Office staff are authorized to handle medical records □ 10 □
and are Finger print identified in the departmental policy and
procedure manual
63. The Medical Office, medical records department is organized □ 10 □
according to the standard practices of the American Society of
Medical Records Librarians and is professionally managed
64. Patient inactive medical records are stored and/or retained in the □ 10 □
Medical office according to applicable State laws
65. Medical Records department storage data is secured off site □ 10 □
66. Current Authorized copy of Policy and Procedure manual is □ 10 □
accessible to the Medical Records staff and are read to
understanding.

SECTION – VII MEDICAL OFFICE, ENVIRONMENTAL SERVICES

67. Supplies and equipment used in the care and maintenance of the □ 10 □
Medical ffice are stored in an organized, clean and secure
Environment
68. Scheduled maintenance of the general area (walls, windows, □ 10 □
floors, etc.)of the medical office once every seven (7) days or
as needed.

69. Scheduled maintenance of the general areas (trash removal, □ 10 □
toilet areas etc.) are accomplished as needed or every 24 hours
70. Scheduled maintenance for all clinical areas (all examining □ 10 □
Rooms or clinical areas are accomplished after every patient
has been seen for any reason
71. All Medical Office maintenance services are the responsibility □ 10 □
of a contracted company

Page 8 of 10

YES AV NO

72. All Medical Office maintenance services are the responsibility of as □ 10 □
many medical office employees as are needed to accomplish the task.

73. Bio-hazard medical waste and sharps are removed from the premises □ 10 □
of the medical office daily by a contracted company.
74. Radioactive waste is removed from the premises of the medical office □ 10 □
as needed by a contracted company.
75. Calibration, testing and repair of all clinical and diagnostic equipment □ 10 □
Contracted company, on a scheduled basis (calibration) or as needed
76. The Medical Office is equipped with a power generator of adequate □ 10 □
size and wattage for use to serve as a source of alternative power in
case of a general area or internal power outage.
77. Flammable or toxic cleaning materials used in the cleaning and □ 10 □
maintenance of the Medical Office are stored in a secure and proper
manner
78. An eye-wash station is located in a properly marked place in the □ 10 □
clinical area of the Medical Office
79. There is a separate room used for the storage of sterile supplies and □ 10 □
80. There is a separate room used for the storage of clean and □ 10 □
non-sterile supplies and equipment
81. There is a separate room used for the clean, washing, and sterilization □ 10 □
82. Current Authorized copy of Policy and Procedure manual is □ 10 □
available and accessible to the Environmental Services staff and are read to
understanding.

SECTION – VIII MEDICAL OFFICE, CLINICAL SERVICES

83. The patients of this Medical Office are NOT directed to a specific □ 10 □
pharmacy to purchase prescription medicines
84. The Medical Director or Physician Owner do NOT sell prescription □ 10 □
medicines from this Medical Office
85. The Medical Director or Physician Owner of this medical office has no □ 10 □
financial or partnership with any Pharmacy licensed to do business in
America
86. Medications prescribed for patients are done so with professional □ 10 □
knowledge, applicable quantity and dosage for diagnosed clinical
indications
Page 9 of 10

YES AV NO
87. The Medical Director, Physician Owner or any physician licensed to □ 10 □
Practice medicine in this medical office participates in the CMS
Sponsored Physician Voluntary Reporting Program (PVRP)
88. All medical equipment in this medical office is subject to regularly □ 10 □
scheduled maintenance for operational accuracy and efficiency
89. A medical equipment maintenance log is maintained in this medical □ 10 □
office to document the results of scheduled maintenance.
90. All prescribed treatments in this Medical Office are approved by the □ 10 □
Food and Drug Administration
91. The clinical staff of this Medical Office are always professionally □ 10 □
attired to perform the clinical task of their assigned positions
92. The Medical Director or Physician Owner of the Medical Office □ 10 □
are licensed and Responsible for the clinical and non-clinical
operations of the facility.
93. Hard copy evidence of license to practice medicine in the residence □ 10 □
state for all physicians (including Physicians providing patient
coverage services)are on file in the human resources department
94. Hard copy evidence of registered staff licensed to assist physicians □ 10 □
(registered nurse, certified nurse practitioner, physician assistant) are
on file in the human resources department.
95. Hard copy evidence of license or registration for physical therapist, □ 10 □
medical technologist, radiology technologist are on file in the
human resources department.
96. A licensed Clinical Pathologist is responsible for the operation of the □ 10 □
on-site clinical diagnostic laboratory services in this medical office.

97. A licensed Clinical Radiologist is responsible for the operation of the □ 10 □
on-site Radiology service in this Medical Office
98. A licensed Physiatrist board certified in Physical Medicine is □ 10 □
responsible for the operation of the on-site physical therapy in
this medical office

SECTION – IX OFF SITE CLINICAL SUPPORT YES AV NO

99. Pre-arranged Emergency medical services are documented, □ 10 □
confirmed and in place.
100. Pre-arranged medical office after hours on-call physician coverage □ 10 □
are documented, confirmed, and in place
Page 10 of 10

YES AV NO

101. Medical Office electronic and surveillance security system □ 10 □
is operational and in place
102. Live security personnel on site during regular medical □ 10 □
office hours
103. Outside Medical Office public notification of □ 10 □
Medical Office Emergency Telephone Number
104. Outside Medical Office public notification of □ 10 □
ToxicologyTelephone numbers are posted

SECTION – X MISCELLANEOUS AUDIT ITEMS

105. Medical Office audit charge deposit submitted with □ 10 □
106. Other _______________________________________ □ 10 □
107. Other _______________________________________ □ 10 □
108. Other _______________________________________ □ 10 □

Audit Start Date _____________________________ Audit Complete Date ________________

Audit Start Time ____________________________ Audit Complete Time _______________

IMPROVEMENT OF HEALTH CARE DELIVERY IN AMERICA:
Medical Office Compliance Certification System Development
Implementation

Exhibit Number 03

CENTER FOR MEDICAL OFFICE COMPLIANCE CERTIFICATION
AUDIT VALUATION REPORT

SECTION COMPLIANCE AUDIT
DESCRIPTION
MAXIMUM
COMPLIANCE
VALUATION
MEDICAL
OFFICE
VALUATION
I Patient Arrival Activities 89 Example 85 only
II Patient Non-Clinical Activities 69 60
III Patient Medical Billing Activities 102 50
IV Medical Office, Accounts Payable 84 80
V Medical Office, Purchasing & Stores 71 70
VI Medical Office, Medical Records 92 40
VII Medical Office, Environmental
Services
116 80
VIII Medical Office, Clinical Services 180 90
IX Off Site Clinical Support 60 60
X Miscellaneous Survey Items 40 30

XI Maximum Compliance Survey
Valuation
903 Example 645
XIV Minimum Valuation For Compliance
Certification
632.1 (70%) Example 71%
XIII Medical Office Closure
Recommendation
361.2 (40%)
XIV Medical Office Compliance
Certification Status
C NC

C = Compliance certification NC = Non-Compliance

Auditor Recommendation

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Auditor Name (please print) ________________________________________I.D. No. _________

Auditor Name (Signature ) _________________________________________________________

Audit Date _________________________________

1 of 1
IMPROVEMENT OF HEALTH CARE DELIVERY IN AMERICA:
Medical Office Compliance Certification System Development
Implementation

Exhibit Number 04

MEDICAL OFFICE COMPLIANCE CERTIFICATION AUDIT
CORRECTIVE ACTION PLAN
(Please send this completed document (USPS Certified mail) to the agency within 30 days of last CMOCC audit)

____1
st
Audit ____ 2
nd
Audit ____3
rd
Audit ____ 4
th
Audit ____ 5
th
Audit ____ Corrective
Action Plan Audit

Other __________________________________________________________________________

Re-Audit Request Date__________________Submit Date __________________Time _________

Medical Office Name _____________________________________________________________

Medical Office Location Address ___________________________________________________

City / State / Postal Code __________________________________________________________

Current Compliance Status ____________________________As Of Date ___________________

Comments: _____________________________________________________________________

_______________________________________________________________________________

Previous Audit Date _____________Auditor Name _______________________ I.D. No. ______

Compliance Auditor Name For Re-Audit __________________________I.D. No. ____________

Medical Office Staff Audit Attendant Name ______________________Title _________________

1. Non-Compliant, Section No. ______________ Section Valuation _______________________

1a. _________ Attached Corrective Action Plan

2. Non-Compliant, Section No. ______________ Section Valuation _______________________

2a. _________ Attached Corrective Action Plan

3. Non-Compliant, Section No. ______________ Section Valuation _______________________

3a. __________ Attached Corrective Action Plan

NOTE; If additional items are needed for this section, do so using the format above with sequential
numbering.

Page 1 of 2
SECTION BELOW FOR CMOCC USE ONLY

□ Corrective Action Plan Acceptable □ Corrective Action Plan
Unacceptable

Medical Office Re-Schedule Audit Date _______________________

Re-Audit Notification Sent Date _____________________________

Re-Schedule Audit Authorized By _______________________________ Title ________

Authorizing Person I.D. No.________________ Authorization Date ________________

Medical Office Closure Recommendation:

Notification to Local Health Department, City __________________________________

City / State / Postal Code __________________________Telephone No. ____________

Health Department Section Name ____________________ Section ________________

Section Department Contact Name _______________________Title _______________

Notification Correspondence Sent Date __________________

By CMOCC Authorization Name __________________________Title _____________

Page 2 of 2

IMPROVEMENT OF HEALTH CARE DELIVERY IN AMERICA :
Medical Office Compliance Certification System Development
Implementation
Exhibit Number 05

CENTER FOR MEDICAL OFFICE COMPLIANCE CERTIFICATION
AUDIT REQUEST ACKNOWLEDGEMENT LETTER

March 26, 2011

Henry L. Bumper, M.D., Medical Center
ATT: Henry L. Bumper, M.D., Medical Director
1412 Cross Street, Suite 207
Anchor Locking, California 90725

Dear Dr. Bumper,

The Center For Medical Office Compliance Certification has received your request for a
certification audit of your medical office. Your medical office is located in Region V of the
Centers’ audit areas, If you have questions or a need for information, please contact our Regional
Supervisor at:
Center For Medical Office Compliance Certification
ATT: Margaret J. Dalphine, FACHE,, Supervisor, Region 5
Furnace Creek, Region 5
147 First Street, Suite 209
Furnace Creek, California 91876-1234
1-800-256-8713

The enclosed audit application must be completed by you and sent to the Furnace Cree,
Region 5 Compliance Center. Upon our receipt of your original application signed by the Medical
Director or Physician Owner, your application will be date and time stamped to establish our
receipt of the document.

The audit notification date and time will be sent to your mailing address via USPS
Certified Mail, Return Receipt Requested. This document will show the name(s) of the auditor
team (if appropriate) and their identification number(s). The date and time of your medical office
audit will serve as confirmation of our presence in your office to conduct the audit.

Please assign a member of your staff to accompany the auditor(s) while on the premises.
If you find it necessary to postpone or change your audit appointment, please do so within five
business days of the date on this correspondence without penalty. This office will provide a one
time, reschedule of your audit at a time that is more convenient to your schedule.

If this office is not notified of your request for a postponement or change of your audit
appointment in a timely manner, your medical office will receive a letter of non-compliance, no
re-schedule for one calendar year and charged with the expense of our auditor staff in your office.

We look forward to serving you. Thank you for your cooperation.
Sincerely,
Margaret J. Dalphine, FACHE, Supervisor
CMOCC Region 5, Furnace Creek, California
cc : Center For Compliance Certification, Director of National Regions
: Region 5, File: Henry R. Carmen, R.N. Assigned Auditor
1 of 1
IMPROVEMENT OF HEALTH CARE DELIVERY IN AMERICA :
Medical Office Compliance Certification System Development
Implementation

Exhibit Number 06

Clinical Case Description Sample

12-05-06 Patient Mary Doe presented to the ophthalmologist
surgery center for a scheduled cataract removal of the
left eye that had been described to her as a simple un-
complicated procedure. Ms. Doe had undergone a
similar cataract removal of the right eye by the same
ophthalmologist in 2003 without any complications.
The patients’ level of confidence made her mentally
secure regarding the physicians’ professional abilities.
Procedural charges were covered by federal and private
medical insurance in the amount of $ 3,800.

12-06-06 Following the initial cataract surgery of the left eye, the
Ophthalmology surgeon reported to Ms. Doe that an
accident had occurred during the cataract removal, The
cataract debris and the lens had slipped into the vitreous
humor of the eye ball.

To correct the error she would have to be seen by a retina
Surgeon whose medical specialty was to correct such
accidents by removing the cataract debris and the re-
positioning of the lens. This out-patient procedure required
admission into a general hospital that is equipped for the
surgical procedure. The cost of the surgery plus the cost of
the hospital admission was covered by federal and private
health insurance benefits. Medical billing in the
amount of $ 11,100.

12-07-06 Medical office visit #1 post operative follow-up. The expense
was covered by federal and private health insurance benefits
in the amount of $ 375.

01-15-07 Medical office visit #2 retina specialist for the level of
pressure in the eye. The expense was covered by federal
and private health insurance benefits in the amount of $ 300.

1 of 4
01-25-07 Medical office visit #3 retina specialist for progress evaluation
The expense was covered by federal and private health
Insurance benefits in the amount of $ 325.
02-05-07 Medical office #4 retina specialist for progress evaluation/
The expense was covered by federal and private health insurance
benefits in the amount of $ 325.

02-16-07 During this medical office visit #5 the surgeon evaluated the
result of the surgical procedure. He reported to Ms. Doe that
the lens had not been re-positioned correctly and that she
would need to be re-admitted to the hospital for the second
re-positioning procedure.

The level of mental anxiety associated with this episode is now
very high for Ms. Doe. The expense of the out-patient hospital
re-admission was covered by federal and private health
insurance benefits in the amount of $ 10,200.

03-17-07 Medical office visit #6 was for the purpose of evaluating the
results of the second surgical lens re-positioning procedure.
multiple prescription medicines (eye drops) are now
necessary which incurred additional cost. The expense of
the medical office visit plus the cost of the prescription
medicines was covered by federal and private health
insurance benefits in the amount of $ 300.

04-02-07 Medical office visit #7 was to evaluate the level of visual
acuity of the second lens re-positioning and the effect of
the prescribed medicines. The expense of the prescription
was a personal deductible expense to Ms. Doe of $ 180.

The cost of the same medical office visit was covered by
federal and private health insurance benefits in the
amount of $ 450.

04-20-07 Medical office visit #8 was to evaluate the effectiveness of
the prescription medication and the condition of the healing
process. The cost of the medical office visit was covered by
federal and private health insurance benefits in the amount of
$ 300.

2 of 4
05-16-07: Medical office visit #9 was to evaluate the progress of the
post surgical procedure. Additional medicines were prescribed
to hasten the healing process and to decrease the collection
of fluid in the eye and to protect against potential infection.
The deductible expense for the medication (re-fills) was a
personal expense for Ms. Doe in the amount of $ 65.

The cost of the medical office visit #9 was to evaluate the
effectiveness of the prescribed medication. The cost of the
medical office visit was covered by federal and private
health insurance benefits in the amount of $ 300.

06-12-07 Medical office visit #10 was to evaluate the effectiveness of
the prescription medication and to conduct a visual sight
test. The cost of the medical office visit was covered by
federal and private health insurance benefits in the amount of
$ 300.

07-17-07 Medical office visit #11 was to evaluate the effectiveness of
the prescription medication and the need to delete the use of
one or more of the prescriptions. The cost of the medical
office visit was covered by federal and private health
insurance benefits in the amount of
$ 300.

08-06-07 Medical office visit #12 was to the office of the first
Ophthalmologist that performed the left eye cataract
removal procedure. The purpose of the office visit was to
evaluate the need for a change in the reading and seeing
prescription glasses. Ms. Doe needed a change in the
prescription eye glasses. The cost of the medical office visit
and a change in the eye glasses prescription was covered
by federal and private health insurance benefits in the
amount of $ 475.

09-04-07 Medical office visit #13 was to evaluate the effectiveness of
the new prescription for the reading glasses. The cost of
the medical office visit was covered by federal and private
health insurance benefits in the amount of $ 300.

09-11-07 Medical office visit #14 was to evaluate the effectiveness of
the eye glasses and to make changes in the prescription.
the cost of the medical office visit was covered by federal
and private health insurance benefits in the amount of $ 340.

3 of 4
10-22-07 Medical office visit #15 was to evaluate the results of the
cataract removal, the surgical lens positioning and re-
positioning procedures, the effectiveness of the medication
and the changes in the eye glasses prescription. The cost
of the medical office visit was covered by federal and
private health insurance benefits in the amount of $ 300.

The final medical expenses associated with this case are not available. the patient
is currently under follow-up care because her discomfort and vision have not
returned to normal.

∙ Projected cost of uncomplicated surgical cataract removal $ 3,800.

∙ Cost of 1
st
Corrective Surgical Procedure $ 11,100

∙ Cost of 2
nd
Corrective Surgical Procedure $ 10,200

∙ Cost of multiple (15) medical office visits $ 4,066

∙ Cost of Rx Medications and Rx Glasses $ 2,010

∙ Personal Patient Out-Of-Pocket expense $ 2,400

∙ Cost of errors by Two (2) Physicians
(charges paid by Insurance Carriers) $ 29,776

4 of 4

POTENTIAL MANPOWER REQUIREMENT FOR FULLY OPERATIONAL
NATIONAL MEDICAL OFFICE COMPLIANCE CERTIFICATION SYSTEM

Exhibit Number 07 1 of 2

Regional
Assignment
States Private
Medical
Offices
( * )
Human
Resource
Requirements
(***)
State
Population
( ** )
Population
Size
( Rank )
I Connecticut 11,019 220 3,483,372 30
I Maine 3,721 74 1,305,728 41
I Massachusetts 25,675 514 6,433,422 13
I New
Hampshire
3,173 63 1,287,687 42
I New Jersey 24,988 500 8,638,396 10
I Rhode Island 3,337 67 1,076,164 44
I Vermont 2,109 42 619,107 50
II Delaware 2,236 45 817,491 46
II Maryland 19,355 387 5,508,909 19
II New York 59.483 1,190 19,190,115 3
II Pennsylvania 34,472 689 12,365,455 6
II Washington,
D.C
3,736 75 563,384 51
III Indiana 13,054 261 6,195,643 14
III Kentucky 8,629 173 4,117,827 26
III Michigan 27,550 551 10,079,985 8
III North Carolina 19,268 385 8,407,248 11
III Tennessee 14,021 288 5,841,748 16
III Virginia 18,685 374 7,386,330 12
III West Virginia 4,088 82 1,910,354 38
III Wisconsin 12,959 259 5.472,299 20
IV Alabama 9,599 192 4,500,752 23
IV Florida 39,667 793 17,019,068 4
IV Georgia 19,002 380 8,684,715 9
IV Louisiana 10,979 220 4,496,334 24
IV Mississippi 5,407 108 2,881,281 32
IV South Carolina 9,525 191 4,147,152 25
V Arkansas 5,208 104 2,725,714 33
V Illinois 33,476 670 12,653,544 5
V Iowa 6,370 127 2,944,062 31
V Minnesota 13,115 262 5,059,375 21
V Missouri 13,657 273 5,704,484 17
VI Kansas 6,087 122 2,723,507 34
VI Nebraska 4,181 84 1,739,291 39
VI Texas 43,398 868 22,118,509 2
VI Oregon 9,840 197 3,559,596 28
VII Colorado 10,996 220 4,550,688 22
VII Idaho 2,434 49 1,366,332 40
VII New Mexico 4,416 88 1,874,614 37
VII Montana 2,112 42 917,621 45
VII Utah 4,599 92 2,351,467 35
VII Wyoming 1,537 31 501,242 52
page 2 of 2
Regional
Assignment
States Private
Medical
Offices
( * )
Human
Resource
Requirements
(***)
State
Population
( ** )
Population
Size
( Rank )
VIII Alaska 992 20 648,818 48
VIII Arizona 11,591 232 5,580,811 18
VIII California 85,805 1,716 35,484,453 1
VIII Hawaii 3,550 71 1,257,608 43
VIII Nevada 4,318 86 2,241,154 36
VIII Washington 16,006 320 6,131,445 15
National CMOCC - 16 - -
8 TOTALS 719,269 14,385 252,345,560

Data Source: (*) 2006 American Hospital Association Guide;
`
(**) Google, USA Population Distribution / State

(***) CMOCC Manpower Requirement / State and Center
Management

Asset Metadata

Creator Nowlin, Thomas Alexander, III (author)

Core Title Improvement of health care delivery in America: medical office compliance certification system implementation

Contributor Electronically uploaded by the author (provenance)

School School of Policy, Planning and Development

Degree Doctor of Policy, Planning & Development

Degree Program Policy, Planning, and Development

Publication Date 09/18/2012

Defense Date 06/12/2011

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag medical office compliance system implementation,OAI-PMH Harvest

Language English

Advisor Lewis, LaVonna Blair (committee chair), Baxter, Iris (committee member), Marco, Noachim (committee member), Markland, Francis S., Jr. (committee member), Richardson, Harry W. (committee member)

Creator Email iiitan@abcglobal.net,tnowlin@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c3-96714

Unique identifier UC11289500

Identifier usctheses-c3-96714 (legacy record id)

Legacy Identifier etd-NowlinThom-1201.pdf

Dmrecord 96714

Document Type Dissertation

Rights Nowlin, Thomas Alexander, III

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Abstract (if available)

Abstract This project will provide an audit system that is designed to improve the delivery of health care at the physician's private medical office. The new audit system, Medical Office Compliance Certification Implementation (MOCC) will focus upon the non-clinical operation of the private medical office. The purpose of the MOCC audit system is to assist with improving the delivery of quality health care to the patients visiting a private medical office.