Need To Audit

What monitoring, auditing, and reporting are needed? What should be audited and how often should it be audited? Auditors can help answer those questions. Their task is to develop a process to identify exposures within their organizations. This task, however, is not simple. It requires a clear understanding of the organization’s inner workings and of the regulatory environment in which the organization functions. One way to demonstrate an effective program is to have a strong auditing and monitoring process- in fact, auditing and monitoring is an essential element under the OIG Compliance Program Guidance. Regular auditing also ensures that an organization operates effectively and efficiently.

A Concurrent Chart Audit by an experienced Nurse Auditor can improve charge capture by utilizing clinical as well as billing knowledge. Therefore, the nurse auditor can reduce revenue loss, insure proper charging protocols are being followed and further assist in the correction plans with departmental managers regarding areas of concern. A Concurrent Audit can be described as a complete audit on a non-disputed claim, completed within 30 days of patient discharge. Concurrent audits should include a random sample including all payer types including inpatient and outpatient based upon a percentage of the facilities daily revenue.

Audits in their never ending effort to reduce risk, legal and financial exposure, and adverse events, help to verify that management controls are in place and effective. Each department of the hospital has unique risks, For example, the urgent pace of patient treatment in Trauma and ER opens it to a myriad of potential problems with EMTALA. Another high potential for risk is Pharmacy. Hospitals must control pharmaceuticals to avoid inventory shrinkage, ineffective workflow processes, and noncompliance with federal and state regulations. Because such departmental problems can draw intense scrutiny from the government and private payers, auditors must identify and monitor them on a regular basis.

Although they focus on healing, hospitals are businesses and management must concentrate on surviving in tough financial times. Auditors are the facilities first line of defense against misstated financial results. In addition to reviewing financial reports, gathering audit outcome stats, auditors must ensure that the central billing office runs effectively as possible. It is apparent that auditing must be conducted in all departments on a monthly basis to assure the organizations financial well being.

— Julie Doumad RN, BSN, CMAS

Director of Audit Services

(American Healthcare Audit Professionals, Inc.)