Provider Audits

A key component of program compliance monitoring is risk-based audits. Audits allow us to check whether a provider has the appropriate systems, processes and governance arrangements in place and is meeting the program requirements. Signals that may trigger an audit include results of claiming data analysis, claims audits, complaints etc.

Provider audits can vary in type and scope. There are two types of audits undertaken: targeted and random. Targeted audits are based on risk profiling and assessments. Random audits are not risked based and complement targeted audits. Random audits are undertaken to support quality assurance and monitor the efficacy of the audit program. Audits can be general, covering all program requirements or limited scope, focusing on a specific requirement such as MHLT or refitting. Regular claims audits are also undertaken. Providers may be subject to a follow-up audit if there were serious issues of non-compliance identified in an audit.

There are four stages to an audit

Diagram - Stages of a Program Audit

Compliance Monitoring and Support Framework