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 created the previous day according to the Service Level Agreement (SLA).
Generation of a monthly aggregate report with a detailed quantitative analysis including:

• Oversized cases detected during the month.
• Dispensing of uncovered medications during the month.
• Oversized investigations or services.
• Investigations, medications, or services not justified.

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.