Auditing and Monitoring in Healthcare: Ensuring Integrity and Compliance with Hospital Reviews

Last Updated June 25, 2024

Auditing and Monitoring in Healthcare: Ensuring Integrity and Compliance with Hospital Reviews

Maintaining compliance with regulatory standards is not just a matter of best practice in our industry – it’s a legal and ethical imperative. Furthermore, ensuring every submitted claim accurately reflects the services provided and meets the necessary criteria for reimbursement directly contributes to the financial stability and reputation of any healthcare institution. This is where the importance of hospital reviews in compliance plans becomes abundantly clear.

The Purpose of Healthcare Compliance Hospital Reviews

Healthcare facilities, entrusted with providing essential services and high-quality care to their communities, face unique challenges in navigating the complexities of compliance. With a reliance on internal staff to uphold regulatory requirements and accurately process claims, there’s a delicate balance between delivering quality care and safeguarding against potential penalties. An effective auditing and monitoring program serves multiple crucial purposes:

Ensuring Documentation and Compliance

Providers can ensure proper coding and compliance by regularly auditing and monitoring their processes. This ensures that services meet the requirements set forth by coding guidelines and third-party payers.

Demonstrating Compliance Effectiveness

Auditing and monitoring help demonstrate the effectiveness of an organization’s compliance program by maintaining a high level of accuracy in audits. This ensures adherence to policies and procedures and provides tangible evidence of the organization’s commitment to compliance.

Training and Education

Through the audit and monitoring process, providers and employees can be trained and educated on the requirements for maintaining integrity and preventing, detecting, and correcting compliance issues. This proactive approach helps mitigate risks and fosters a culture of compliance throughout the organization.

Differentiating Between Auditing and Monitoring

It’s important to understand the distinction between auditing and monitoring in the context of compliance programs.

Auditing involves retrospectively reviewing documentation to ensure adherence to procedures and accuracy in service documentation. It focuses on evaluating and improving the effectiveness of processes and controls, often using sampling techniques to assess risk areas.

Monitoring, on the other hand, involves ongoing checking and measuring to ensure that processes are working as intended. It includes internal data integrity checks, validation of risk areas, and continuous verification of policy adherence.

Elements of a Thorough Auditing & Monitoring Program

To establish an effective audit and monitoring program, facilities must adhere to key principles and elements outlined by regulatory bodies such as the Office of Inspector General (OIG). These elements include:

Implementing Policies and Procedures: Developing comprehensive policies and procedures that outline compliance expectations and guidelines is the foundation of any audit and monitoring program. At this step, provide a template for how the coding audit data should be uploaded to the auditing software and the tools needed to effectively perform the audit.
Designating Compliance Oversight: Designating a compliance officer and compliance committee responsible for overseeing the audit and monitoring program ensures accountability and program effectiveness. Furthermore, compile a list of all the parties being audited and any specific coding requirements the facility tracks (for data collection, quality control, or other purposes).
Conducting Training and Education: Providing practical training and education to employees and providers ensures awareness of compliance requirements and fosters a culture of accountability.
Developing Communication Channels: Establishing effective lines of communication facilitates the reporting of compliance concerns identified during the audits and ensures timely response and resolution.
Performing Regularly Scheduled Audits and Ongoing Monitoring: Regular internal audits and monitoring activities help identify compliance gaps, mitigate risks, and measure program effectiveness. Establish a schedule for when these audits need to take place and work plan for the audit process. Before the audit is performed, determine the scope of the audit, sample size, and the type of results that are expected.
Reviewing Audit Results: Deliver and review the results with relevant staff and stakeholders. Provide a summary report that highlights the audit’s scope, methodology, and key findings. This report should also include recommendations for improvements to address any identified deficiencies.
Enforcing Standards: Enforcing compliance standards through disciplinary guidelines ensures accountability and promotes adherence to policies and procedures. Determine the procedures for how to hold the responsible parties accountable if they are not following guidelines or need additional training.
Responding to Detected Problems: Promptly responding to detected compliance issues and undertaking corrective action demonstrates a commitment to addressing and resolving deficiencies. The results of ongoing auditing and monitoring efforts should be used to drive strategic decision-making at the organization.

Checklist for a Thorough Auditing & Monitoring Program

Our team of coding and auditing consultants compiled a thorough checklist to help you prepare for your next audit.

Additionally, the OIG has established a monitoring toolkit for providers to monitor their compliance program’s effectiveness effectively.

Upholding Compliance and Hospital Reviews with a Third-Party Expert

With a proactive approach to auditing and monitoring, health systems and private practices can navigate the complexities of compliance with confidence and honesty, safeguarding their financial stability and reputation in the process. Our coding compliance auditors at YES are experts in auditing and monitoring.

When you place your trust in a Compliance Expert like the Team at YES, you can be assured that our team will identify any areas of improvement to increase revenue, improve processes, and enhance compliance. Review our list of compliance audit services and touch base with our team today.

Auditing and Monitoring in Healthcare: Ensuring Integrity and Compliance with Hospital Reviews