Medical auditing comprises a set of methods that seek to evaluate the services provided by a health unit or service provider. It is an extremely important tool in the management of the institution, seeking, in addition to presenting qualitative and quantitative parameters for the unit, to offer relevant information to other related institutions, such as health plan operators.

These, in turn, need to be aware of the costs and quality indicators of the units that comprise them. Therefore, a good audit — reliable and effective — is essential. In this scenario, technology appears as a great ally, making the audit process more organized, efficient, transparent and reducing costs.

In this article we select the benefits of artificial intelligence technologies when applied in the medical audit process. Check out!

What are the main aspects of the medical audit?

When a health institution is contracted to provide a service, whether directly with the patient (or beneficiary) or through a health plan operator, there is a contract that specifies which services will be provided, what the quality standard is and which are the rights and duties of both parties to the agreement.

Therefore, audit work — which can be carried out either by a team or by a single, duly qualified professional — requires the professional to be attentive and enforce contractual clauses. The professional or team's role is to analyze the procedures carried out by the health institution, in order to determine:

• their adequacy to the need;
• whether they were applied correctly;
• whether they agree with the availability of resources;
• meet the established quality standard.

Thus, the audit's ultimate objective is to prevent any of the parties to the agreement from feeling aggrieved and to ensure that no contractual clause is being neglected by the parties. In practice, it seeks to avoid losses, improve the process and optimize the costs of that event.

As an example, we can mention an institution that, in a given period of time, carried out more of a given exam than was usual. Or the opposite: an institution that carried out less of this exam than was common.

In these situations, it is up to the auditor to analyze, monitor and present a plan so that, for example, next month the resources necessary to carry out this examination are spent in the best possible way, seeking to make forecasts that are in line with fluctuations in demand.

Furthermore, the duties of the medical audit include the responsibility of verifying the quality of care, becoming aware of patients' satisfaction or dissatisfaction in relation to the performance of employees, the structure of the location and the administration of the health unit, in addition to analyzing whether the institution's practices are in accordance with established ethical conduct.

What are the disadvantages of old-fashioned auditing?

Audit processes collect a large amount of information and require a systematic analysis of this data. Therefore, when data collection and analysis are done manually by the auditor or audit team, even if the data is analyzed in spreadsheets, the process may present a series of errors or mistakes, such as:

• the auditor can infer his analysis on a biased sample, that is, one that does not represent the whole;
• the analysis is subject to the auditor's qualitative criteria — Art. No. 6 of CFM Resolution No. 1,614/2001, which regulates the practice of medical auditing, establishes that the auditor cannot “exaggerate or omit facts”, but this is a subjective item;
• human errors, such as collecting or passing data incorrectly;
• difficulty in accessing previous data, as it needs to be searched manually.

What is artificial intelligence (AI)?

Human beings have the ability to learn. We can reach a conclusion after analyzing some information and thus make a decision. Likewise, artificial intelligence seeks to develop a software capable of not only analyzing data and, from it, filtering relevant information, but also creating more complex analyzes and even correcting itself, generating an autonomous and more dynamic process.

What are the benefits of AI in medical audits?

The automated process guarantees greater reliability in obtaining and processing data, in addition to making it simpler to display. AI also makes medical auditing more organized and transparent, since reliable software will not be subject to subjective changes, in addition to providing more security and credibility.

How can artificial intelligence help save money?

AI also generates more efficiency in the procedure, since in addition to having a great information processing capacity, artificial intelligence is also capable of analyzing data from previous audits, creating a certain standardization of results — being more sensitive and capable of detecting changes in the flow of information.

This helps guide the focus of audit analysis, creating more accurate forecasts and offering more concrete information, which helps in decision making. This process agility makes the audit more effective, both for the health unit providing the service and for the health plan operator, saving time and money.

How important is good quality software?

Choosing reliable software to automate the medical audit process is extremely important, as it will handle the information — and it will be up to it to conduct procedures and, consequently, be responsible for efficiency in reducing costs.

A company with solid references, which offers transparency, support and process integration is essential. Flexibility and possibility of customization when adopting the system are also interesting differentiators.

Therefore, artificial intelligence technologies have great potential in medical auditing and can be great allies in this process, automating it, making it more reliable, transparent, practical and reducing costs. When choosing a technology, it is important to be careful and look for a trustworthy company that offers excellent quality software.

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