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Understanding Healthcare Compliance Audits

Updated: Apr 25, 2021

Healthcare Compliance Audits

Due to the high-risk nature of their work, it is critically important for healthcare organizations to understand and adhere to process of following rules and regulations related to their operations and the protection of sensitive data. Healthcare compliance pertains to the practices, rules and issues that govern how healthcare organizations operate. This includes patient safety, the protection of sensitive patient data, billing practices and other operational concerns.

What is a Healthcare Compliance Audit?

A compliance audit is an independent evaluation that examines an organization’s adherence to the laws, rules, and regulations (as well as internal guidelines) that govern its operations. Every healthcare organization must develop an effective plan to achieve healthcare compliance in order to maintain efficient operations while providing a high-quality of patient care. Failure to comply with the Department of Health and Human Services (HHS), Office of Inspector General (OIG) can mean significant penalties to the organization.

Possible penalties for compliance failures can include:

  • Civil and criminal actions

  • Exclusion from Medicare and Medicaid participation

  • Referral to the relevant state medical board

Healthcare audits can uncover potential compliance issues and offer suggestions for improvements. The audit process can also serve to help organizations remain in compliance as healthcare regulations grow and change over time.

Achieving Healthcare Compliance

As healthcare laws and regulations can and develop, it can be challenging for organizations maintain effective compliance and meet state and federal standards. Given this, the Office of the Inspector General (OIG) has outlined the components of effective healthcare compliance. These fundamentals include:

  • Documenting policies, procedures, and guidelines for conduct

  • Appointing a Compliance Officer, along with a committee to manage program oversight

  • Utilizing due diligence in the delegation of authority

  • Educating employees to understand how compliance impacts their job roles

  • Performing internal audits

  • Administering standards through disciplinary guidelines

  • Promptly reacting to offenses and performing corrective actions

Types of Healthcare Audits

Below is a list of the most common types of healthcare audits and the benefits to each of them:

Random Audit

A random audit is conducted with the goal of gaining an understanding of how the organization functions. Random Audits are performed on an ad-hoc basis (typically without a scheduling date) to review a variety of claims in order to compare them to relevant regulations. These audits can quickly identify potential problem areas and opportunities for improvement.

Comprehensive Audit

Comprehensive Audits are used to perform a thorough review of previously audited claims and the supporting documents. Comprehensive Audits delve into more detail than Random Audits.

Hybrid Audits

Hybrid audits are essentially a combination Random and Comprehensive Audits. Hybrid auditors often review data for both Random and Comprehensive assessments. This type of audit tends to offer a deeper level of insight into different types of claims and actions.

Quality Improvement Audit

Quality improvement audits are used to simultaneously examine data from both providers and patients. These audits are conducted regularly to uncover potential issues and identify strategies for improvement. To be thorough, a wide range of patients with varying conditions are reviewed.

The Benefits of an LMS for Healthcare Compliance

Employee training is a key component for a healthcare organization’s success, especially when it comes to ensuring employees are aware and trained in all areas of compliance. Changing regulations and employee turnover can lead to lower quality patient care while risking non-compliant operations and behaviors. A powerful Learning Management System (LMS) for healthcare organizations can help mitigate staff training challenges. At the same time, effective eLearning can help to ensure compliance and increase employee and patient satisfaction.

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