Why is Hiring an Independent Certified Internal Auditor a Good Idea?

A Discussion Paper for Healthy Contracts Legislation

Hiring an Independent Certified Internal Auditor (CIA) for health plans contracting with providers of mental and behavioral health services is highly beneficial. It would solve the problems and challenges Healthplans face because Healthplan management is driven by profit, while independent certified internal auditor are driven to provide accurate and useful information which can be used by management to make decisions and take action, and also to inform stakeholders. Independent CIAs are “truth tellers”. Independent CIAs ensure compliance with regulatory requirements and industry standards, such as those from the Centers for Medicare and Medicaid Services (CMS) and the National Commission on Quality Assurance (NCQA), helping to mitigate legal risks and uphold patient confidentiality, maintain accurate billing, and quality care. CIAs promote transparency and accountability, building trust among stakeholders through objective assessments and audits. CIAs facilitate effective communication and collaboration between providers and health plans, identifying areas for improvement and fostering constructive dialogues. CIAs improve financial performance and operational efficiency by identifying inefficiencies and optimizing revenue cycles. Additionally, CIAs support data-driven decision-making by leveraging data analytics to provide valuable insights. CIAs routine audits foster a culture of continuous improvement and help mitigate risks related to patient safety, data security, and financial integrity, ensuring high ethical standards are maintained in all aspects of healthcare delivery and financial management.

Qualifications for becoming an Independent Certified Internal Auditor in health plan contracting for mental and behavioral health services include a combination of educational credentials, professional experience, certification, and adherence to ethical standards. CIAs must have at least a bachelor’s degree, relevant experience in internal auditing, quality assurance, or risk management, and must pass the CIA exam. They must adhere to the Code of Ethics established by The Institute of Internal Auditors (IIA), and must maintain independence and objectivity. CIAs must possess strong analytical and communication skills, have in-depth knowledge of healthcare regulations, and be capable of developing comprehensive audit programs and engaging with various stakeholders to ensure transparency and accountability. CIAs must understand value-based payment models and comply with state and federal laws governing healthcare contracts to effectively oversee and evaluate health plan operations and support high-quality mental and behavioral health services.

Hiring an Independent Certified Internal Auditor (CIA) for health plans contracting with providers of mental and behavioral health services is beneficial for many reasons:

1. Ensuring Compliance and Reducing Legal Risks

Independent CIAs are knowledgeable about regulatory requirements and industry standards. Their audits help ensure that health plans and providers comply with relevant laws, such as those which govern the Centers for Medicare and Medicaid Services (CMS) and the National Commission on Quality Assurance (NCQA). This compliance is crucial for mental and behavioral health services, where patient confidentiality, accurate billing, and quality of care are paramount. Regular audits help identify and mitigate potential risks, reducing the likelihood of legal issues, fines, or penalties.

2. Enhancing Transparency and Accountability

Independent CIAs promote transparency and accountability in the contracting process between providers and health plans. Their objective assessments and audit findings help build trust among stakeholders, including patients, providers, health plans, and regulatory bodies. Transparent audit processes demonstrate commitment to ethical practices and continuous improvement, which are essential for maintaining the integrity of mental and behavioral health services.

3. Facilitating Effective Communication and Collaboration

Involvement of independent CIAs can facilitate effective communication and collaboration between providers and health plans. Audits can identify areas for improvement, leading to constructive dialogues and collaborative efforts to address issues. Open communication and collaboration are vital for aligning incentives, resolving conflicts, and ensuring that the contracting process serves the best interests of all stakeholders, including patients.

4. Improving Financial Performance and Operational Efficiency

Independent CIAs can identify inefficiencies, inaccuracies, or potential revenue leakages in billing, coding, and reimbursement processes. By ensuring accurate documentation and coding, CIAs help optimize revenue cycles and improve overall financial performance for both providers and health plans. Additionally, their recommendations can lead to streamlined operations and increased efficiency in the delivery of mental and behavioral health services.

5. Supporting Data-Driven Decision Making

CIAs leverage data analytics to identify trends, risks, and areas for improvement. Their audit findings and recommendations provide valuable insights that support data-driven decision-making for both providers and health plans. This data-driven approach helps stakeholders proactively address issues, allocate resources effectively, and implement strategic initiatives to enhance patient care and operational efficiency.

6. Fostering Continuous Improvement

Regular audits conducted by independent CIAs foster a culture of continuous improvement in mental and behavioral health services. Their ongoing feedback on the effectiveness of policies, procedures, and controls allows providers and health plans to make necessary adjustments and improvements. Their continuous monitoring and evaluation help ensure that services remain responsive to changing regulations, patient needs, and industry best practices.

7. Mitigating Risks and Enhancing Security

Independent CIAs are skilled in risk assessment and management. Their audit programs can identify potential risks related to patient safety, data security, and financial integrity. By addressing these risks proactively, providers and health plans can enhance their security measures, protect patient data, and ensure the safe delivery of mental and behavioral health services.

8. Ensuring Ethical Practices

CIAs uphold high ethical standards in their audit practices. By auditing contracts and operations, they help ensure that providers and health plans adhere to ethical guidelines in patient care, billing, and overall operations. This ethical oversight is crucial in mental and behavioral health services, where the vulnerability of patients necessitates the highest standards of care and integrity.

Qualifications for an Independent Certified Internal Auditor in Health Plan Contracting for Mental and Behavioral Health Services

The qualifications for an Independent Certified Internal Auditor (CIA) in health plan contracting for mental and behavioral health services include specific educational, experiential, and ethical standards:

1. Educational Requirements

Bachelor’s Degree or Higher: Candidates must hold at least a bachelor’s degree or equivalent from an accredited institution. This is a fundamental requirement for entering the CIA program.

Alternative Pathways: In some cases, candidates can qualify with a high school diploma or equivalent if they have substantial relevant work experience.

2. Professional Experience

Internal Audit Experience: Candidates must have relevant experience in internal auditing, quality assurance, risk management, compliance, or related fields. Specifically, two of the five required years of experience must be recent, within the past three years.

Work History: A minimum of five years of work history is often required, with a focus on roles that involve auditing, compliance, or risk management.

3. Certification and Training

Certified Internal Auditor (CIA) Designation: Candidates must pass the CIA exam, which consists of three parts, and meet the continuing professional education (CPE) requirements to maintain their certification[.

Ongoing Education: CIAs are required to stay abreast of current developments and improvements in the field through continuing education.

4. Ethical Standards

Code of Ethics: CIAs must adhere to a Code of Ethics established by The Institute of Internal Auditors (IIA), which emphasizes integrity, objectivity, confidentiality, and competency.

Independence: CIAs must operate independently and objectively, without any conflict of interest that could compromise their impartiality.

5. Specific Skills and Competencies

Analytical Skills: Strong analytical skills to evaluate complex data and identify trends, risks, and areas for improvement.

Communication Skills: Excellent communication skills to effectively report findings and recommendations to stakeholders, including health plan management and providers.

Knowledge of Healthcare Regulations: In-depth knowledge of healthcare regulations, particularly those related to mental and behavioral health services, such as CMS guidelines and NCQA standards.

6. Role-Specific Requirements

Audit Program Development: Ability to create and implement comprehensive audit programs that include ongoing risk assessment and mitigation strategies.

Stakeholder Engagement: Skills in engaging with various stakeholders, including providers, patients, and regulatory bodies, to gather feedback and ensure transparency and accountability.

Reporting and Transparency: Capability to manage and report audit findings through public platforms to promote transparency and accountability.

7. Regulatory and Compliance Knowledge

Understanding of Value-Based Payment Models: Familiarity with value-based payment (VBP) models and alternative payment methods (APMs) to ensure that contracts align with these frameworks and support high-quality care.

Compliance with State and Federal Laws: Knowledge of state and federal laws governing healthcare contracts, including those specific to mental and behavioral health services.

DISCLAIMER and PURPOSE: This discussion document is intended for training, education, and 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.

For more information see: https://www.mentorresearch.org/disclaimer-and-purpose