Do you require an audit?

Determining the necessary monitoring, auditing, and reporting protocols is essential for organizational integrity. Key considerations include identifying what should be audited and establishing appropriate audit frequencies. Auditors play a critical role in developing effective processes to recognize potential exposures within organizations. This responsibility demands a comprehensive understanding of both internal operations and the regulatory landscape governing the organization. Establishing robust auditing and monitoring procedures demonstrates the effectiveness of compliance programs; indeed, such practices are fundamental according to OIG Compliance Program Guidance. Regular audits also contribute to operational efficiency and effectiveness.

A Concurrent Chart Audit conducted by an experienced Nurse Auditor enhances charge capture by leveraging clinical expertise alongside billing acumen. Nurse auditors mitigate revenue loss, ensure correct charging procedures, and assist departmental managers with corrective actions on identified areas of concern. A Concurrent Audit typically involves a thorough review of non-contested claims within 30 days post-discharge. These audits should encompass a random sample representing all payer types, both inpatient and outpatient—corresponding to a percentage of the facility’s daily revenue.

Auditing serves as a continuous strategy to minimize risk, legal and financial exposure, and adverse events, thereby verifying the adequacy and effectiveness of management controls. Each hospital department faces distinct risks and compliance. Similarly, pharmacy operations require strict oversight to prevent inventory losses, optimize workflow, and ensure adherence to federal and state regulations. Such departmental issues may attract scrutiny from regulatory agencies and private payers, underscoring the necessity for proactive identification and monitoring by auditors.

Despite their primary focus on patient care, hospitals must also address business and financial sustainability, particularly in challenging economic contexts. Auditors serve as the first line of defense against inaccurate financial reporting. In addition to reviewing financial documentation and compiling audit results, auditors must verify that central billing functions operate at optimal efficiency. It is imperative that audits are conducted monthly across all departments to safeguard the financial stability of the organization.

Julie Doumad, RN, BSN, CCFA, CMAS

Director of Audit services 

American Healthcare Audit Professionals Inc.