HCP 516 Week 4 Root Cause Analysis in Compliance Example

Not One Root but Five: A Root Cause Analysis of Overbilled Therapy Units That Looked Past the Therapists to the Template, the Training and the Billing System

[Student Name]

University of Phoenix

HCP/516: Auditing, Monitoring and Corrective Action in Compliance

Week 4 Assignment

[Instructor Name]

[Date]

The therapy company, its errors, interviews and findings are composites written for a model paper; research and published guidance come from the sources listed.

The timed units audit at the composite outpatient therapy company found 26 errors in the company-wide sample and 12 more in the focused review of the outlier clinic. The compliance manager's next task was to explain why they happened. A clinic director's first reaction was that some therapists needed to be retrained. This paper describes the root cause analysis that followed and why it reached a broader conclusion.

What Root Cause Analysis Is For

Root cause analysis examines a problem to find the conditions that produced it, so that actions can prevent it from happening again. In compliance, it turns audit findings into corrective action that addresses causes rather than symptoms. Its value depends on the quality of the investigation and the strength of the actions that follow.

Known Weaknesses of the Method

Root cause analysis has critics. Peerally et al. (2017), surveying how the method is used in health care, argued that investigations are often of variable quality, that the search for a single root cause misrepresents how problems arise from multiple interacting factors and that recommended actions are frequently weak, such as training or new policies, and poorly implemented. A critique of the popular five-whys technique argued that it tends to produce a single chain of causes, depends heavily on the investigator and can stop at whatever answer is convenient (Card, 2017). The manager designed the analysis to avoid these traps.

The Team

The team included the compliance manager, two therapists from different clinics, a biller, the outlier clinic's director and the company's electronic documentation analyst. Including people who do the work brings knowledge of how things actually happen, not how policy says they happen. The team met four times over three weeks, and the manager asked the therapists to speak first at each meeting so that managers' views did not set the direction.

Mapping the Process

The team mapped a visit from treatment to claim: the therapist delivers services, documents them in a template, selects codes and units, the note is signed, the billing system creates a claim and a biller reviews and submits it. At each step, the team asked what could allow a unit error and what could catch one. Two steps allowed errors, documentation and unit selection, and no step reliably caught them.

The Cause-and-Effect Diagram

The team sorted possible causes on a fishbone diagram, one branch each for people, methods, tools, training, oversight and environment. Contributions under each came from the audit data, the therapist interviews and the process map.

Cause One: A Different Rule Learned Elsewhere

Sixteen of the 38 errors came from therapists billing one unit for each service lasting eight minutes or more rather than totaling timed minutes. Thirteen of those 16 were made by therapists hired within the past two years from other employers or from outpatient settings billed under different payer rules. The company's orientation did not cover unit rules.

Cause Two: The Template

The documentation template listed services with checkboxes and minutes for each but did not calculate total timed minutes or show supported units. The outlier clinic used an older, locally customized version that did not require minutes at all, which explained most of its errors. No one at the company level had known that clinics could customize templates, and three other clinics had made smaller changes of their own. When the form does not add up the minutes, every therapist becomes a calculator, and some calculate differently.

Cause Three: No Check Before Billing

The billing system accepted whatever units the therapist selected. Billers were trained to check codes against the payer's rules but not to compare units against documented minutes, and had no report to do so.

Cause Four: Oversight That Looked Elsewhere

Clinic managers' monthly chart checks looked for signatures and plan of care dates, not unit calculations. Monitoring reports existed only since the new compliance program began.

Cause Five: Productivity Pressure

Therapists were measured on visits per day and units per visit, and two clinics posted units per visit on a board. Interviews suggested this did not cause deliberate overbilling but made therapists reluctant to bill fewer units when in doubt.

Testing the Causes

The team tested each cause against data. Errors were concentrated among recently hired therapists and at the clinic with the old template, supporting causes one and two. No errors were caught before billing in the sample, supporting cause three. Clinics that posted units per visit had slightly higher error rates, weaker but consistent support for cause five.

What the Analysis Ruled Out

Good analysis also rules things out. The team considered whether therapists were deliberately inflating units. Nothing supported it: errors ran in both directions in a few cases, therapists readily explained their reasoning, errors followed training history and template version rather than individuals' pay and none of the therapists received compensation tied to units. The team also considered whether the billing vendor's software had changed units after submission and found no evidence of it in claim histories. Recording what was ruled out, and why, protects the company if its conclusions are later questioned and keeps the analysis from sliding into blame.

Why Training Alone Would Have Failed

The clinic director's first instinct, retraining, would have helped with the first cause but left the others in place. New therapists would keep arriving with different habits, the template would still not add minutes and no one would catch errors before claims went out. Within a year, the same audit would likely find the same problems among a new group of therapists. The manager used this point with the leadership team to justify the cost of template and billing changes.

Ranking the Actions

A widely used guide to improving root cause analyses in health care ranks actions by strength: stronger actions change design, such as forcing functions and automation; intermediate actions include standardization, checklists and redundancy; weaker actions include training, warnings and new policies (National Patient Safety Foundation, 2015). The team proposed stronger actions first: a template that automatically totals timed minutes and displays supported units, and a billing edit that holds any claim where units exceed those supported. Intermediate actions include standardizing all clinics on one template and adding unit checks to manager reviews. Weaker but necessary actions include training new hires on unit rules and replacing the posted units-per-visit board with a documentation quality measure.

Conclusion

The first reaction, retrain some therapists, would have addressed one of five causes with the weakest kind of action. A team that included frontline staff, a process map and a cause-and-effect diagram found causes in hiring, templates, billing controls, oversight and incentives, each tested against audit data. Ranking actions by strength led to design changes that make the right number of units the default, setting up the corrective action plan that follows.

References

Card, A. J. (2017). The problem with "5 whys." BMJ Quality & Safety, 26(8), 671-677. https://doi.org/10.1136/bmjqs-2016-005849

National Patient Safety Foundation. (2015). RCA2: Improving root cause analyses and actions to prevent harm. Institute for Healthcare Improvement. https://www.ihi.org/resources/tools/rca2-improving-root-cause-analyses-and-actions-prevent-harm

Peerally, M. F., Carr, S., Waring, J., & Dixon-Woods, M. (2017). The problem with root cause analysis. BMJ Quality & Safety, 26(5), 417-422. https://doi.org/10.1136/bmjqs-2016-005511