Healthcare organizations with delegation agreements with private or government insurance programs are wise to prepare for, at a minimum, audits on an annual basis. Insurance providers use these audits to better ensure the healthcare business complies with the expectations outlined within contractual agreements while also providing some oversight.
Be warned: These audits are increasing in frequency
Although an annual audit is common, recent reports have found that payers are increasing the frequency with which they conduct these audits. Reasons for the uptick in audit frequency vary, but often include concerns about inaccurate provider directories and increased scrutiny from the federal government.
An ounce of prevention is worth a pound of cure: Tips to prepare for a delegation audit
Four things an organization can do to prepare for these audits include:
- Review. Make it a habit to regularly review and update credentialing policies and procedures.
- Organize. Have provider applications readily available. Make sure they are properly completed and include signatures.
- Report. Report any changes within the organization as needed, such as a change in organization ownership and provider location.
- Prepare. Regular mock audits provide an opportunity to check for compliance and adjust as needed to help increase the odds an actual audit runs smoothly. It is helpful to ask specific questions during this practice audit. These questions can look into the timeliness of tests and claims, presence of proper policies and procedures, the training and education of staff and the presence of proper security measures to better ensure the safety of sensitive data.
Whether regularly scheduled or random, those who undergo an audit may face allegations of a failure to meet the agreed upon requirements. This can lead to costly penalties. Options are available to challenge these claims.