medical audits

A medical audit consists of a variety of moving parts. And one of the most impactful parts is an auditor’s use of big data, which is something that most of the healthcare industry struggles to navigate. 80% of healthcare data is unstructured, and because of this, auditors aren’t able to make proper use of the insights into patient health and operational standing that the data provide. While this is just one of the most well-known hurdles with medical audits and auditing processes, facilities still face other difficulties.

An additional concern is not all hospitals have dedicated clinical auditing practices or departments. Therefore, some healthcare professionals may not realize that an internal audit could prevent the need for an external audit from being triggered. This means that the tools you use to manage your audits matter.

Investing in your internal auditing processes allows you to incorporate more transparency and accountability for your facilities’ management systems and practices. Outlining key performance indicators ultimately results in improved patient care, facility growth and productivity, and better financial performance.

Understanding the Role of Medical Audits

A medical audit is meant to detect errors while helping providers determine why those errors occurred. Hospital audits provide a great deal of value to facilities because they make improvements possible without experiencing significant risk. Practices or policies can directly affect the care you deliver to patients.

Auditing makes discrepancy identification simpler, making it a powerful tool. Internal audits in healthcare, for example, help facilities ensure that legal standards and regulatory changes are followed and adjusted as needed by all facility staff. This means risks are more easily mitigated, areas of noncompliance are detected early, and there is an increase in positive patient experiences.

Internal and External Medical Audits: Understanding the Difference

Internal Audits in Healthcare

Internal audits in healthcare are conducted by the institution’s staff or, in many cases, designated internal auditors. The primary objective of internal audits in healthcare is to assess the effectiveness of internal controls, ensure compliance with established policies, and identify areas for improvement.

These audits focus on operational efficiency, financial accuracy, and better adherence to clinical guidelines. With regular internal audits, hospitals and other healthcare facilities can proactively address potential issues before they escalate into significant problems over time while going undetected.

External Medical Audits

In contrast to an internal audit, external audits are carried out by independent bodies or external auditors, often called Recovery Audit Contractors. The point of this type of audit is to provide an assessment from an unbiased stance. Frequently done manually, these audits are often mandated by regulatory agencies. As we’ve mentioned, external medical audits provide an unbiased assessment of a hospital’s operations, which ensures they meet industry standards and legal requirements.

They are primarily used as a benchmark for quality and compliance. Overall, facilities can expect an external audit to offer valuable insights that internal audits might overlook. Things going overlooked are often a result of familiarity with the facility, whether intended or unintended. External solutions eliminate this while also preventing documentation errors and mishaps with reporting.

What Do Internal and External Medical Audits Looks Like

Internal audits can often range from:

  • Clinical Audits
  • Random Audits
  • Federal Government Audits
  • Commercial Payer Audits
  • Quality Improvement Audits
  • Operational Audits

Each audit will have a different purpose. For example, in a hybrid audit, the focus would combine a random and comprehensive approach. The point of this is to gather a detailed range of insights related to items such as claim submissions, documentation discrepancies, and potential downfalls of operations.

Audits that focus on quality improvement are exactly as they sound. The purpose of these audits is to understand the entire patient experience. This can be helpful with implementing new improvements across the patient care life cycle from admission to discharge.

As another example, financial audits are done to verify the accuracy of a hospital’s financial statements. They are also meant to ensure compliance with financial regulations. This type of audit could be both internal and external, as well.

Understanding the Audit Cycle

The audit cycle usually consists of four primary steps. Those steps include:

  • Determining the topic or focus of the audit
  • Agreeing on the audit criteria
  • Collecting relevant data
  • Initiating data analysis and comparing results to current regulatory standards

This cycle is meant to help auditors, whether internal or external, follow a series of best practices to ensure the accuracy of audit results. Overall, a medical audit plays a pivotal role in quality assurance, patient safety, and fraud prevention and reduction.

Navigating Medical Audits With the Right Software

Medical audits are more than a regulatory requirement; they are a strategic tool. A hospital medical audit is essential for the advancement and sustainability of the facility performing it.

Compliance tracking and monitoring can be difficult for any facility. However, by using the right type of compliance management software, you easily obtain the capability to simplify, standardize, and track your progress within an audit lifecycle. Compliancy Group offers facilities the ability to manage compliance across multiple regulations and facilities.

Everything you need, from automating your processes to streamlining your audit criteria, can be found in one place. Start with a demo today.

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