Independent Certified Internal Auditors Shall Create And Implement Audit Programs For Mental And Behavioral Health Contracts And Policies
Having Independent Certified Internal Auditors (CIAs) create and implement audit programs for health plan contracting in mental and behavioral health services is a good idea for several reasons, as highlighted in the provided sources:
An audit program for mental and behavioral health contracting with more than one contract or policy involves a systematic and comprehensive approach to evaluating and ensuring compliance, transparency, and effectiveness of the contracts and policies in place. Here are the key components and steps involved in creating and implementing such an audit program:
1. Establishing the Scope and Objectives
Define the Scope: Determine the specific contracts and policies to be audited, including their terms, conditions, and the parties involved.
Set Objectives: Establish clear objectives for the audit, such as ensuring compliance with regulatory requirements, assessing the effectiveness of value-based payment models, and identifying areas for improvement.
2. Developing Audit Criteria and Standards
Regulatory Compliance: Ensure that the audit criteria include compliance with relevant laws and regulations, such as those from the Centers for Medicare and Medicaid Services (CMS) and the National Commission on Quality Assurance (NCQA).
Best Practices: Incorporate industry best practices and standards, such as those recommended by the Institute of Internal Auditors (IIA).
3. Creating an Audit Plan
Audit Schedule: Develop a schedule for conducting audits, including the frequency and timing of audits for different contracts and policies.
Resource Allocation: Allocate the necessary resources, including personnel, tools, and technology, to conduct the audits effectively.
4. Conducting Risk Assessments
Identify Risks: Identify potential risks related to the contracts and policies, such as financial risks, compliance risks, and operational risks.
Risk Control Matrix: Develop a risk control matrix to assess the likelihood and impact of identified risks and to determine appropriate mitigation strategies.
5. Performing the Audit
Data Collection: Collect relevant data and documentation, including contract terms, payment records, and performance metrics.
Interviews and Observations: Conduct interviews with key stakeholders, such as providers, Healthplan administrators, and patients, to gather insights and observations.
Testing and Validation: Perform tests to validate the accuracy and completeness of the data and to ensure that the contracts and policies are being implemented as intended.
6. Analyzing Findings and Reporting
Analyze Results: Analyze the audit findings to identify areas of noncompliance, inefficiencies, and opportunities for improvement.
Audit Report: Prepare a comprehensive audit report that includes the findings, recommendations, and action plans for addressing identified issues. The report should be clear, concise, and written in plain, understandable language.
7. Implementing Recommendations and Mitigation Strategies
Action Plans: Develop action plans to address the audit findings and implement the recommended changes.
Follow-Up Audits: Conduct follow-up audits to ensure that the recommended changes have been implemented effectively and that the identified issues have been resolved.
8. Ensuring Continuous Improvement
Feedback Mechanisms: Establish mechanisms for ongoing feedback from stakeholders to continuously improve the audit program and the contracts and policies.
Training and Education: Provide training and education to stakeholders on the audit process, findings, and best practices for compliance and performance improvement.
9. Maintaining Transparency and Accountability
Public Reporting: Post the results of the audits and the mitigation options on a public electronic platform webpage to ensure transparency and accountability.
Stakeholder Engagement: Engage with stakeholders throughout the audit process to build trust and ensure that their concerns and feedback are addressed.
Example of an Audit Program for Mental and Behavioral Health Contracting
Audit Program Components:
1. Scope and Objectives:
Audit all value-based payment (VBP) contracts and policies for mental and behavioral health services.
Ensure compliance with CMS and NCQA guidelines.
Assess the effectiveness of VBP models in improving care quality and outcomes.
2. Audit Criteria and Standards:
Compliance with federal and state regulations.
Adherence to best practices in VBP contracting.
Evaluation of performance metrics and outcomes.
3. Audit Plan:
Quarterly audits for all VBP contracts.
Allocation of a dedicated audit team with expertise in mental and behavioral health services.
4. Risk Assessments:
Identify financial, compliance, and operational risks.
Develop a risk control matrix to prioritize and mitigate risks.
5. Audit Execution:
Collect and review contract documents, payment records, and performance data.
Conduct interviews with providers, health plan administrators, and patients.
Validate data accuracy and completeness through testing.
6. Analysis and Reporting:
Analyze audit findings to identify noncompliance and inefficiencies.
Prepare a detailed audit report with findings, recommendations, and action plans.
7. Implementation and Follow-Up:
Develop and implement action plans to address audit findings.
Conduct follow-up audits to ensure effective implementation of recommendations.
8. Continuous Improvement:
Establish feedback mechanisms for ongoing stakeholder input.
Provide training on audit processes and best practices.
9. Transparency and Accountability:
Post audit results and mitigation options on a public electronic platform.
Engage stakeholders throughout the audit process to build trust and ensure accountability.
By implementing a comprehensive audit program, health plans can ensure that their contracts and policies for mental and behavioral health services are compliant, effective, and aligned with best practices, ultimately leading to improved care quality and outcomes for patients.
DISCLAIMER and PURPOSE: This discussion document is intended for training, educational, and or research purposes only. The information contained herein is based on the data and perspectives available at the time of writing. It is subject to revision as new information and viewpoints emerge.