OUR SERVICES

INDEPENDENT PROVIDER AUDITS

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Our independent provider audits evaluate the complete service-delivery environment, not just what appears in a policy or medical record.

 

Reviews may include:

• Onsite facility and program observations
• Clinical record and documentation reviews
• Staffing and credential verification
• Staff-to-member ratio assessments
• Scope-of-practice and supervision reviews
• Comparison of scheduled, documented, billed, and observed services
• Level-of-care and program-fidelity assessments
• Medical-necessity reviews
• Member and staff interviews
• Environment-of-care observations
• Billing and claims sampling
• Contractual and regulatory compliance reviews
• Policies, procedures, and internal-control assessments

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FRAUD, WASTE, AND ABUSE RISK ASSESSMENTS

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Identify Vulnerabilities Before They Become Systemic. Fraud, waste, and abuse concerns often emerge through a combination of billing patterns, documentation deficiencies, weak oversight, inappropriate staffing, operational pressure, and services that do not match what was authorized or billed.

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Services may include:

• Claims and utilization pattern reviews
• Targeted clinical-record validation
• Staffing and service-delivery comparisons
• Billing-code and level-of-care analysis
• Duplicate, excessive, or incompatible service reviews
• Identification of unsupported or potentially inflated services
• Review of referral, authorization, and discharge patterns
• Evaluation of high-risk programs or provider types
• Assessment of internal controls and monitoring processes
• Root-cause analysis of recurring payment or compliance concerns
• Recommendations for referral, recovery, education, or corrective action

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COMPLIANCE PROGRAM DEVELOPMENT

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TruNorth helps organizations create practical compliance programs that reflect how their services actually operate.

 

Support may include:

• Compliance program design and implementation
• Policy and procedure development
• Regulatory and contractual crosswalks
• Risk-assessment frameworks
• Internal auditing and monitoring plans
• Reporting and escalation pathways
• Documentation and billing standards
• Compliance committee structures
• Leadership and board reporting tools
• Investigation protocols
• Corrective action processes
• Staff education plans
• Annual compliance work plans
• Effectiveness measures and dashboards

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CORRECTIVE ACTION PLANNING AND MONITORING

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Move From Identified Deficiencies to Measurable Improvement. A corrective action plan should do more than restate a problem. It should identify the cause, establish ownership, define measurable expectations, and verify that improvement is sustained.

 

TruNorth can provide:

• Root-cause analysis
• Risk-prioritized corrective action plans
• Clear action owners and due dates
• Measurable completion criteria
• Evidence requirements
• Technical assistance
• Implementation check-ins
• Follow-up record reviews
• Validation audits
• Performance dashboards
• Sustainability monitoring
• Closure recommendations

 

PROVIDER READINESS AND CREDENTIALING SUPPORT

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Make better decisions before services begin. Effective oversight begins before a provider enters the network or expands its services. TruNorth can assess whether providers have the operational and clinical infrastructure necessary to deliver the programs they propose.

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Readiness reviews may evaluate:

• Leadership and organizational structure
• Staff qualifications and workforce capacity
• Clinical supervision
• Required policies and procedures
• Program descriptions and curricula
• Documentation systems
• Quality-management processes
• Billing controls
• Facility readiness
• Referral and admission criteria
•  Discharge and continuity-of-care processes
• Emergency and safety procedures
• Ability to meet specific level-of-care requirements

 

CLINICAL QUALITY AND LEVEL-OF-CARE REVIEWS

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TruNorth evaluates whether clinical programs are appropriately designed, staffed, and operated for the members they serve.

 

Reviews may address:

• Program structure and clinical intensity
• Medical necessity
• Level-of-care alignment
• Treatment planning
• Evidence-based practices
• Individual, group, and family services
• Multidisciplinary involvement
• Care coordination
• Medication-management integration
• Crisis planning
• Progress measurement
• Continued-service criteria
• Transition and discharge planning
• Readmissions and avoidable utilization
• Member engagement and outcomes

 

OPERATIONAL AND WORKFLOW ASSESSMENTS

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Turn complex processes into clear, accountable systems. Operational weaknesses can lead to delays, inconsistent decisions, documentation gaps, employee frustration, and compliance risk.

 

TruNorth helps organizations evaluate and improve:

• Clinical and administrative workflows
• Roles and decision-making authority
• Intake and referral processes
• Authorization and utilization-management processes
• Care coordination
• Provider monitoring
• Complaint and incident escalation
• Cross-department communication
• Quality-control checkpoints
• Workload distribution
• Productivity standards
• Documentation processes
• Reporting and performance dashboards

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CLINICAL AND COMPLIANCE TRAINING

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Give organizations and their employees the tools to recognize and prevent risk. Effective training must connect requirements to real decisions organizations employees face in their daily work.

 

Available topics may include:

• Fraud, waste, and abuse prevention
• Ethical documentation and billing
• Medical necessity
• Scope of practice
• Clinical supervision
• Level-of-care requirements
• Audit readiness
• Incident reporting
• Conflicts of interest
• Leadership accountability
• Corrective action planning
• Quality assurance
• Internal monitoring
• Protecting members and public resources

 

Training can be tailored for executive leaders, clinical staff, compliance teams, care managers, provider-network teams, utilization-management staff, and frontline employees.

 

INTERIM LEADERSHIP AND SPECIAL-PROJECT SUPPORT

 

Experienced leadership when the work cannot wait. Organizations may need immediate expertise during leadership transitions, program launches, regulatory reviews, corrective actions, or periods of rapid growth.

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TruNorth can provide temporary or project-based support for:

• Compliance and quality leadership
• Behavioral health program oversight
• Provider-network improvement
• Audit preparation and response
• Corrective action implementation
• Policy-development initiatives
• New-program readiness
• High-risk provider reviews
• Workflow redesign
• Cross-functional improvement projects

 

Engagements are structured around defined objectives, deliverables, and transition plans.

 

CUSTOM ENGAGEMENTS

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Complex Problems Rarely Fit Into a Standard Package

TruNorth develops customized engagements for organizations facing emerging risks, sensitive provider concerns, unusual utilization patterns, or system-level performance challenges.

 

Depending on the need, an engagement may combine:

• Data analysis
• Document and record review
• Onsite observation
• Stakeholder interviews
• Regulatory research
• Operational assessment
• Clinical consultation
• Executive facilitation
• Corrective action development
• Follow-up monitoring

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