Audits have always been considered the most effective and imperative means of ascertaining appropriate and ethical financial management, regulatory compliances as well as for unearthing process flaws and errors. This specially holds true for Medical Payers and Providers when it comes to Medical claims and billings.

Healthcare Audits in the GCC region are currently targeted towards Providers and can be defined as:

• Processes used to assess, evaluate and improve quality of care given by providers in a systematic way.
• Part of clinical governance to safeguard quality of clinical care for patients.

So, who runs a check on the Payers? Payers are often known to misinterpret facts or neglect to examine claims appropriately so as to justify a denial and boost their bottom lines. Denied medical claims can cost medical practices revenue, not only because of the time and effort spent in rebilling but also as penalties and fees levied for re-audits and compliance re-checks by health authorities. Claims management remains a major RCM stumbling block countered by providers causing losses of millions in revenue annually. These factors can affect patient care, as providers try to tweak their processes to comply with regulations while ensuring low claim denial.

Moreover, audits should be a process which aims to educate the providers/payers in best market practices and compliances, not as a process of punishment. When used as a basis for penalization, providers may tend to look for loopholes to appear compliant during an audit. Some of the areas that are typically vulnerable to fraud or misconduct are:

• Falsification of documents by providers/payers in support of audits.
• Inflation of the number of claims processed audits.
• Altered documents to increase scores.
• Hiding on-going processing errors.
• Failure to process claims properly and then submitting false reports.

With Providers preparing for an audit only to ensure a good score, the current system does not ensure that compliance and quality KPIs are being maintained consistently.

Beyond the penalization model, there exist some serious flaws in the current auditing system viz.

• Most Auditors are not qualified Auditors but experienced coders. Audit is a specialized function that requires the CPMA certification.
• Current auditors are hired locally – creating a conflict of interest. As most auditors would have worked in many of the facilities that they are now auditing, it not only creates a conflict of interest but can seriously compromise the integrity of the audit due to personal/professional biases.
• Lack of provider training and orientation of Audit procedure has led to Providers turning to private pre-audit consultants in preparation for the Audit.
• Private Pre-Auditors who are uninformed or inexperienced seriously compromise overall patient care, quality and provider performance in Audit.

We believe that the only way forward, so as to overcome the aforementioned hurdles would be for contracted Auditors to have not only extensive auditing resources but audit certifications with extensive knowledge and experience in healthcare governance. A regular comprehensive Payers’ Audit process is also much needed to ensure that not just the Provider, but even the Payer is in compliance with the range of contractual and other requirements. Furthermore, the contracted Auditor should never have worked for any local provider/ payer. This prevents any professional bias or conflict of interest.

And finally, a merit-based transparent Auditing systems that incentivizes rather than penalizes providers and payers to consistently upgrade their performances and adhere to total compliances along with comprehensive and continual provider/payer education sessions to enable effective and constant compliance.