What Is Auditing in Healthcare Compliance?

Sarah Jones
woman standing with clipboard looking at the camera

Auditing in healthcare compliance refers to the systematic examination and assessment of healthcare organizations’ operations, processes, policies, and practices. These audits can be completed internally or externally to ensure the organization is in compliance with various regulatory requirements, laws, and industry standards.

There are three main types of healthcare compliance audits:

  • Internal: Organizations should regularly conduct internal audits to assess risks that may have arisen and correct the issues before a regulatory audit.
  • 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.
  • Regulatory: Regulatory agencies, such as the Office of the Inspector General (OIG), conduct audits to ensure organizations are carrying out their responsibilities. These audits can result in fines and other penalties.

What is Healthcare Compliance?

Healthcare compliance is the process of following the laws, regulations, and ethical standards that govern the healthcare industry. It ensures that healthcare organizations and professionals adhere to guidelines that protect patient safety, maintain data privacy, and uphold the integrity of medical practices. Compliance is essential for operating within the legal framework, providing high-quality care, and maintaining the trust of patients and the community​.

Key Elements of a Healthcare Compliance Audit

The primary goal of healthcare compliance auditing is to identify and address areas of non-compliance, mitigate risks, and ensure that the organization adheres to the applicable rules and regulations. Healthcare compliance audits are typically conducted with a specific set of objectives in mind, such as assessing compliance with healthcare laws like HIPAA, the False Claims Act, Stark Law, and others. Auditors aim to determine whether the organization’s practices align with these regulations.

Here are key aspects of auditing in healthcare compliance:

  • Preparation: If your organization initiated the audit, you will have time to prepare in advance. Some regulatory agencies also offer 7 to 60 days notice. Ensure you have records of everything —- remember if it isn’t in writing, it didn’t happen. Here are tips to prepare:
  • Objective Evaluation: Documentation Review: Auditors examine various documents, records, and policies within the healthcare organization to assess whether they meet regulatory requirements. This includes reviewing patient records, billing and coding documentation, contracts, and internal policies and procedures. Using a document management solution that offers reporting can simplify this process.
  • Internal Controls: Auditing in healthcare compliance often focuses on evaluating the effectiveness of the organization’s internal controls and processes. Auditors assess whether there are sufficient controls in place to prevent fraud, ensure accurate billing, and protect patient data.
  • Risk Assessment: Healthcare compliance audits can include a risk assessment to identify potential areas of non-compliance or vulnerabilities. This assessment helps prioritize audit efforts and resource allocation.
  • Sampling and Testing: Auditors may use statistical sampling and testing methods to review a representative sample of records and transactions. This approach allows them to draw conclusions about the organization’s overall compliance based on the sampled data.
  • Interviews and Observation: Auditors may conduct interviews with staff members and observe certain processes to gain insights into the organization’s compliance practices. This can help identify issues that may not be evident from documentation alone.
  • Corrective Action Plans: When non-compliance issues are identified, auditors work with the healthcare organization to develop corrective action plans. These plans outline steps to address and rectify the identified problems and ensure future compliance.
  • Reporting and Communication: After completing the audit, auditors prepare detailed reports that outline their findings, recommendations, and any areas of non-compliance. These reports are typically shared with the organization’s leadership and compliance officers.
  • Continuous Monitoring: Healthcare compliance auditing is not a one-time event. It is an ongoing process, and organizations often establish continuous monitoring mechanisms to ensure that they remain in compliance over time.
  • Regulatory Updates: Healthcare compliance auditors stay up-to-date with changes in healthcare laws and regulations to ensure that audits are conducted with the latest requirements in mind.

Healthcare compliance audits play a critical role in helping healthcare organizations maintain legal and ethical standards, prevent fraud and abuse, protect patient data, and avoid legal penalties. They also contribute to the overall integrity and reputation of healthcare providers and organizations by demonstrating a commitment to compliance with regulatory requirements.

Use Technology To Simplify Auditing in Healthcare Compliance

A comprehensive compliance management platform provides reporting and automations that relieve some of the audit-related stress. All in one platform,  brings together robust document management capabilities and related reporting that makes it easier to ensure all policies and procedures are up-to-date and have been acknowledged by the required employees.  Automated reminders ensure you’re updating policies prior to expiration and electronic multi-signature workflows make it easy to get board approvals and track versions. The reporting and analytics tools bring your document-related data into customizable reports so it’s easy to share information.

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

Find out how MedTrainer offers valuable support to organizations as they undertake this critical process, ultimately contributing to improved compliance and patient care. By systematically addressing compliance risks, healthcare organizations can foster a culture of accountability and ensure the delivery of safe and high-quality healthcare services.


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