The Importance of Internal Healthcare Compliance Audits

Julie Horibe, BSN, RN, CPN
Healthcare compliance audits

As a healthcare professional, it is vital to maintain compliance with the 629 legal and regulatory requirements that govern the delivery of quality care. One effective tool to achieve this is through internal healthcare compliance audits.

This article will delve into the significance of internal healthcare compliance audits, the legal and regulatory requirements, the benefits they offer, and the steps involved in conducting such audits.

What Is an Internal Healthcare Compliance Audit?

Internal healthcare compliance audits ensure that healthcare providers adhere to legal and regulatory standards. These audits help identify non-compliance areas, allowing healthcare organizations to take remedial actions and prevent potential risks. 

Audits fall into three categories:

  1. Internal: Organizations should regularly conduct internal audits to assess risks that may have arisen and correct the issues before a regulatory audit.
  2. Third-Party: Organizations may contract with a third party to conduct an independent audit. The results can be used to make corrections before a regulatory audit.
  3. Regulatory: Regulatory agencies, such as the Office of the Inspector General (OIG), conduct audits to ensure organizations carry out their responsibilities. These audits can result in fines and other penalties.

By conducting regular internal audits, healthcare professionals can minimize issues discovered in an external review by a regulatory agency like the OIG. Internal healthcare compliance audits catch issues before they occur and help you avoid:

  • Financial Penalties: Government agencies can impose substantial fines for non-compliance, leading to a significant economic burden.
  • Legal Consequences: Non-compliance may result in civil or criminal legal actions, damaging the organization’s reputation and its professionals.
  • Loss of Reimbursement: Non-compliant practices may face denials or recoupments of reimbursement from governmental and private payers.
  • Damage to Reputation: Non-compliance can erode patient trust, negatively impacting the practice’s reputation and potential patient volume.

Legal And Regulatory Requirements In Healthcare

More than 620 legal and regulatory requirements govern how the healthcare industry ensures patient safety, privacy, and quality of care. These requirements include but are not limited to:

  1. Health Insurance Portability and Accountability Act (HIPAA): Protects the privacy and security of patients’ health information.
  2. Medicare Access and CHIP Reauthorization Act (MACRA): Promotes value-based care and rewards healthcare providers for quality and performance.
  3. Affordable Care Act (ACA): Ensures access to affordable healthcare and prevents fraud and abuse.
  4. Stark Law: Prohibits physicians from referring Medicare patients for health services to entities with which the physician or an immediate family member has a financial relationship.
  5. Occupational Safety and Health Act: Established the Occupational Safety and Health Administration (OSHA) and created a U.S. law of workplace standards that ensures employees are protected from hazards that compromise their safety and health.

Complying with these requirements is a legal obligation and a moral responsibility to deliver ethical and safe healthcare services.

Internal Healthcare Compliance Audit Structure

Common Internal Audit Types

  • Privacy and Security Audits: Assessing the protection of patient health information and compliance with HIPAA regulations.
  • Coding and Documentation Audits: Review medical coding practices to ensure accuracy, completeness, and compliance with coding guidelines.
  • Financial Audits: Evaluate financial practices, such as billing, reimbursement, and financial reporting, to detect fraudulent or non-compliant activities.
  • Human Resources Audits: Assessing compliance with employment laws, such as equal employment opportunity, wage and hour regulations, and workplace safety.

Internal Healthcare Compliance Audit Process

The first step is establishing an internal compliance audit program that outlines policies, procedures, and training to promote adherence to legal and regulatory requirements. Consider engaging external experts to evaluate compliance protocols and practices unbiasedly.

  1. Risk Assessment: Pinpoint vulnerable areas for targeted attention, ensuring focus on high-risk and crucial aspects.
  2. Planning: Define the scope and objectives of the audit, identify audit areas, and establish a timeline.
  3. Gathering Information: Collect relevant documentation, policies, procedures, and other materials necessary for the audit.
  4. Assessing Compliance: Review the collected information to evaluate compliance with legal and regulatory requirements.
  5. Identifying Gaps: Identify any areas of non-compliance, weaknesses, or opportunities for improvement.
  6. Implementing Corrective Measures: Develop and execute action plans to rectify non-compliance issues and strengthen compliance protocols. It is vital to provide ongoing training and education to all staff members on compliance policies, procedures, and ethical practices.
  7. Monitoring and Follow-up: Regularly monitor compliance and assess the effectiveness of implemented corrective measures. Maintain detailed records of compliance efforts, including audit findings, corrective actions, and monitoring activities.

Common Findings

During internal healthcare compliance audits, specific common findings may emerge. These findings often highlight areas where practices may be at risk of non-compliance. Some common findings include:

  1. Need for documentation to support billed services or procedures.
  2. Adequate training and education on compliance policies and procedures are needed.
  3. Lack of proper safeguards to protect patient health information.
  4. Failure to perform regular risk assessments or address identified risks.
  5. Non-compliance with coding guidelines, resulting in inaccurate billing or reimbursement.

Implement Internal Healthcare Compliance Audit Findings

Internal healthcare compliance audits can be stressful. Compliance management software provides reporting and automation to reduce some of that pressure. MedTrainer’s all-in-one platform brings together robust document management capabilities and related reporting that make it easier to ensure all policies and procedures are up-to-date and have been acknowledged by the required employees.

Our learning management system (LMS) helps deliver compliance training and education to staff with automated completion reminders and customizable reporting that shows all employees have completed the required training. Online incident management helps identify potential issues before they become a problem to effectively reduce your organization’s risk.

See how MedTrainer offers valuable support for internal healthcare compliance audits.


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