Medical Audit CORE BENEFITS:
- Evaluate the clinical performance vs CHI Clinical Guidelines of all the Physicians which identifies opportunities for improvement.
- Inspect claims against fraudulent claims (fraud – abuse).
- Reduce the risk of payors external audit.
- Provide a good payer – provider relationship by reducing the issues to debate over which is much appreciated from the payors.
Medical Audit Functions:
Daily medical audit of all claims generated in the previous day according to SLA.
Generating monthly collective report with a detailed quantitative analysis containing:
- Uncovered cases detected all over the month.
- Uncovered medications dispensed all over the month.
- Uncovered investigations or services.
- Unjustified investigations, medications or services.
Medical Audit Functions:
- Monthly performance report of each doctor concerning any common mistakes, any abuse of services without clear justifications.
- Analysis of the rejections received from insurance companies and detect the invalid reasons of rejections to be discussed during reconciliation process.
- Detection of the valid reasons of rejections and inform the medical director or the insurance manager to be avoided in the future.
- Monthly audit of the inpatient files in order to be sent before the submission date to the insurance companies.
- Monthly steering committee meeting with all concerned stakeholders.
