When it comes to healthcare audit management, the solution boils down to what you will benchmark, training, and the best methods for efficiency within your organization. A lot of industry leaders share the idea that audits are the best start toward better compliance management these days. Your solution depends on exactly what you intend to audit, and hospitals need to consider whether your payer is already doing similar audits.

Top 3 Audit Management Strategies for Providers


Focusing on Healthcare Audit Management. When it comes to healthcare audit management, the solution boils down to what you will benchmark, training, and the best methods for efficiency within your organization. Ensure ongoing contract management and frequently completed compliance audits.

FacilityExecutive.com posted a recent article with an important observation — “proactively managing healthcare assets is independent of what may or may not occur in changes to the Affordable Care Act (ACA).” They followed this statement with a careful list of steps which include “compliance auditing.” Under step three, “develop an appropriate operating model and strategy for world-class service delivery” we find this list:

  • Define the right internal and external capabilities
  • Leverage a sourcing strategy, and maximize economies of scale
  • Ensure ongoing contract management and frequently completed compliance audits
  • Develop and regularly update required ongoing training programs

Service, Coding, Fraud and Cyber Crime Healthcare Audit Management

A recent whitepaper from Frost & Sullivan, “The Increasing Challenge of Managing Regulatory and Compliance Risk,” explores the characteristics of an ideal information platform to manage compliance needs. According to their press release, “the healthcare space is seeking an information management solution that is comprehensive, authoritative, and tailored to the needs of coders and healthcare officials.”  Digital Health Principal Analyst, Victor Camlek for Frost & Sullivan observes, “up-front coding accuracy is crucial to achieving the regulatory compliance needed to ensure fast and timely reimbursements. Such a resource will also provide the basis to develop and update training programs, documentation and policies in the highly-regulated healthcare industry.”

Some healthcare audit management sleuthing can help uncover Medicare and Medicaid fraud, but only, as a recent article in National Review notes, if your audits are set to review not only whether a certain treatment was, in fact, appropriate for what ails Mrs. Jones, but also whether Mrs. Jones exists.  According to Malcolm Sparrow, a Harvard professor of public management who studies medical fraud, the government’s approach long has been backward: “Basically, the audits they’re using on a random sample are nothing like fraud audits,” he told The Nation. “The difference between a fraud audit and a medical review audit — a medical review audit, you’re taking all the information as if it’s true and testing whether the medical judgment seems appropriate. You can use these techniques to see where judgments are unorthodox or payment rules have not been followed, but almost nothing in these methods tests whether the information you have is true.”

 The SSI Group has developed an Audit Management module that tracks existing and incoming audits and protects revenue with complete visibility into audit-associated revenue risks.

The focus on cyber crimes during healthcare audit management. A focus on what exactly to study in your cyber and IT audit and good communication with management emerge as themes in a recent Healthcare IT News article. The authors quote an auditor in a large health system, who observes:

“From our audit perspective, by determining which controls are more critical, based on the audits we can give real-time feedback, here are our findings, here is what needs to be improved, here is what we are doing well. That gets management attention; the auditor report goes to the board of directors. There is awareness brought to the cybersecurity program both to the technical folks and management. This is a slow process, we are not able to do 20 in a year, we are trying to get through all 20 every three years.”

Finally, an article on 6 Top Healthcare Audit Types in Healthcare Finance News, makes a couple of very important points regarding audit duplication: “It is essential that both parties—payers and providers—understand the types of audits payers are conducting, and the reasons behind them. Often, health plan audits parallel internal and external audits already being conducted by the provider; prior knowledge of this is essential to minimizing redundancies.”

The article goes on to give details on this list of essential types of healthcare audits for hospitals:

  1. Risk Adjustment and Medical Record Reviews (MRRs): Medicare Advantage, Medicaid and Commercial Audits—1Q 2015 through 4Q 2015
  2. Medicare Advantage Risk Adjustment Data Validation (RADV)—Annual 2015 (at CMS’s discretion)
  3. Health Effectiveness Data & Information Set (HEDIS) Reviews—1Q through 2Q 2015
  4. Diagnosis Related Group (DRG) Payment Integrity Reviews—Ongoing through Year
  5. Care and Quality Improvement Audits—Ongoing through Year
  6. Five-Star Program (Medicare Advantage)—Ongoing through Year

We’re known for Claims Management solutions at The SSI Group, and while we continue to see our hospital clients make revenue cycle gains with this essential software, we believe that audit technology should start up front at point of service. That’s why we offer a range of successful Access Management solutions to complete our software suite in the last couple of years. Together, these tools will help you focus audits and avoid many of the common errors that good audits uncover.