Process Risk Risk Impact

Incomplete or incorrect patient

Registration & Admission data High

Failure to verify insurance

Registration & Admission eligibility High

Billing Unrecorded services or procedures High

 Incorrect pricing or discount
Billing application Medium

Submission of incomplete or
Claims Management incorrect insurance claims High

Delayed or insufficient follow-up

Claims Management on denied claims Medium

Delayed collections from patients

Collections or insurance companies High
 Cash misappropriation during
Collections manual collection High

Unrecorded or mismanaged
Pharmacy pharmacy sales High

Incorrect application of profit

Pharmacy margins on medicines Medium

Tests performed but not billed due

Diagnostics to human or system errors High
 Discounts on diagnostic services
Diagnostics not authorized Medium

Unbilled surgical procedures,

Operating Room (OR) implants, or consumables High

Unbilled follow-up consultations

or free consultations provided
Consultations without documentation Medium

System bugs causing underbilling

IT Systems or unbilled services High
 Weak monitoring and oversight of
Governance revenue-related metrics High
 Control Objective Control Activities Audit Test Steps

- Automated Data Entry,

Ensure accurate and complete Cross-checking, Verification - Sample Audit, Claims Analysis,
patient data is captured Prompt Cross-check Patient Classifications

- Insurance Verification
Ensure insurance eligibility is verified Workflow, Manual Checks, - Audit Eligibility, Rejection Review,
before service delivery Pre-authorization Requests System Testing

- Real-time Service Capture,

Ensure all services provided are Automated Reconciliation, - Reconcile Service Logs, Audit
captured and billed accurately Manual Review Unbilled Procedures, Spot Checks
 - Pricing Structure Review,
System Controls for Discount - Test Pricing, Review Discount
Ensure accurate pricing and Approval, Audit of Revenue Approvals, Check System-Based
authorized discounts Reports Price Overrides

Ensure all claims are accurate and - Pre-Submission Claim

submitted with proper Review, Coding Accuracy, - Sample Review, Denied Claims
documentation Claim Documentation Analysis, Coding Compliance Check

- Claim Tracking System, - Claims Aging Report Review,

Ensure timely follow-up and Dedicated Follow-Up Team, Follow-Up Audit, Claims Rework
resolution of claims issues Regular Reviews Tracking

- Daily Reconciliation,
Ensure timely and complete revenue Collection Follow-Up - Cash Flow Analysis, Outstanding
collection Procedures, Collection Targets Balances Review, Compliance Test
 - Cash Handling Procedures,
Digital Payment Systems, - Cash Deposit Audit, Check for
Minimize risk of cash handling losses Reconciliation of Cash Payment Gaps, Audit System

- Inventory vs. Sales Reconciliation,

Ensure all pharmacy transactions are - Automated Billing, Inventory Theft Investigation, Audit Sales
accurately recorded Audits, Segregation of Duties Process

Ensure margins comply with policy - Margin Review, Approval

and are consistently applied Workflow for Overrides - Margin Test, Override Audit

Ensure all diagnostic services are - Test Logs, Daily - Test Log vs. Billing, Unbilled Tests
recorded and billed Reconciliation, System Alerts Investigation
Ensure compliance with discount - Approval Workflow, Discount - Discount Approval Review,
authorization policies Reporting System Testing

Ensure all surgeries and consumables - Surgical Logs, Reconciliation - Audit Surgical Logs, Implant
are captured and billed accurately of OR Logs with Billing Billing, Reconciliation Test

Ensure all consultations are billed - Check-In System, Follow-Up - Consultation Billing Review,
appropriately Visit Tracking Policy Compliance

Ensure billing system accuracy and - System Audits, Data Integrity

data integrity Checks - System Testing, Review IT Logs
Strengthen accountability and
monitoring to minimize revenue - Monthly Revenue Reviews, - Management Review, KPI
leakage KPI Dashboards Monitoring
 Responsible Party

Registration Staff

Registration & Billing

Team

Billing Team
Billing Supervisor

Claims Team

Claims Manager

Collection Team
Cashier/Finance Team

Pharmacy Manager

Pharmacy/Finance
Team

Diagnostics Team
Billing Supervisor

OR Coordinator

Outpatient Team

IT Department
Management
 Audit
Risk Control Control Responsi
Process Risk Test
Impact Objective Activities ble Party
Steps

-
Automate - Sample
d Data Audit:
Entry: Review a
Use of sample of
system- patient
based registratio
checks for n forms
mandator for
y fields complete
during ness and
registratio accuracy.
n.

- Claims
- Cross- Analysis:
checking: Investigat
Ensure Manual e rejected
accurate verificatio claims
Incomplet and n of and
e or complete patient identify if
incorrect patient ID, name, errors
Registrati contact, were
patient data is
on & caused by Registrati
data (e.g., High captured and
Admissio incorrect on Staff
demograp to avoid insurance
n
hics, misclassifi details. registratio
insurance cations n.
details). and
rejections
.
hics, misclassifi
insurance cations
details). and
rejections
.

- Cross-
- check
Verificati Patient
on Classificat
Prompt: ions:
Ensure Review
prompts patient
for admission
insurance categorie
details s to
and ensure
eligibility correct
checks classificati
are ons (e.g.,
mandator insured
y. vs. self-
pay).

-
- Audit
Insurance
Eligibility:
Verificati
Check a
on
sample of
Workflow
admission
:
s to
Automate
confirm
d
that
insurance
insurance
verificatio
eligibility
n prior to
was
admission
verified.
.

Ensure
insurance
eligibility
Failure to
is verified
verify
before Registrati
insurance
service on &
eligibility High
delivery Billing
before
to reduce Team
admission
claim
.
denials
and
rework.
 -
- Manual
Rejection
Ensure Checks:
Review:
insurance Staff
Review
eligibility responsibl
Failure to insurance
is verified e for
verify claim
before verifying
insurance rejections Registrati
service insurance
eligibility High to identify on &
delivery eligibility Billing
before errors
to reduce via direct
admission related to Team
claim contact
. eligibility
denials with
verificatio
and insurers.
n.
rework.

- Pre-
- System
authoriza
Testing:
tion
Test the
Requests:
functional
Ensure all
ity of
pre-
insurance
authorizat
verificatio
ion
n
requirem
modules
ents are
in the
complete
registratio
d before
n system
services
for
are
reliability.
rendered.
 - Real-
time
-
Service
Reconcile
Capture:
Service
Implemen
Logs:
t
Compare
electronic
medical
service
service
capture
logs
during
(doctor’s
patient
orders,
encounte
diagnostic
rs (e.g.,
tests)
doctors’
against
orders
billing
logged
records.
immediat
ely).

Ensure all
services
provided,
Unrecord
including -
ed
diagnostic Automate - Audit
services d
tests, Unbilled Billing
or
Billing High treatment Reconcili Procedur Superviso
procedur ation: Use
s, and es: r
es (e.g.,
medicatio automate Review
missed d tools to
ns, are high-risk
charges). reconcile
billed procedur
accuratel patient es or tests
y. records
that
and
might be
billing
missed.
entries in
real-time.
 - Spot
- Manual
Checks:
Review:
Check
Periodic
random
manual
encounte
review of
rs to
service
confirm if
logs to
all
ensure no
services
services
have
are
been
missed.
billed.

- Test
Pricing:
- Pricing Perform
Structure tests on a
Review: sample of
Regular patient
review bills to
and confirm
updates that
of charge correct
masters prices are
and being
pricing charged
databases according
. to the
charge
master.

Ensure
that all
services
Incorrect are
pricing or charged
discount according
applicatio to the Billing
Medium
n leading correct Team
to pricing
underbilli structure
ng. and
authorize
d
discounts.
 - System
Ensure Controls
that all for
services Discount - Review
Incorrect are Approval: Discount
pricing or charged Implemen Approvals
discount according t system- : Review
applicatio to the based approval Billing
Medium
n leading correct checks workflow Team
to pricing that s for any
underbilli structure require discounts,
ng. and manageri checking
authorize al if
d approval appropria
discounts. for te
discounts justificati
exceeding ons are
predefine provided.
d
threshold
s.

- Check
System-
- Audit of
Based
Revenue
Price
Reports:
Overrides
Periodic
: Audit
revenue
instances
audit to
where
ensure
prices are
accurate
manually
applicatio
overridde
n of
n or
pricing.
discounte
d.
 - Pre-
Submissio
- Sample
n Claim
Review:
Review:
Audit a
Implemen
sample of
t a quality
claims
assurance
submitted
process
for
for all
complete
claims
ness and
before
accuracy.
submissio
n.

- Denied
Claims
Analysis:
Review
- Coding denied
Accuracy: claims to
Ensure determin
Ensure proper e if errors
Submissio that all medical occurred
n of claims coding for during
incomplet submitted all submissio
e or are procedur n (e.g.,
Claims incorrect accurate, es. incorrect Claims
Managem insurance High complete, coding, Team
ent claims and missing
leading to supporte informati
denials or d by on).
underpay adequate
ments. document
ation.
denials or d by
underpay adequate
ments. document
ation.

- Coding
Complian
ce Check:
- Claim
Compare
Documen
submitted
tation:
codes
Require
against
complete
the
document
procedur
ation to
es
support
performe
each
d,
claim
ensuring
(e.g.,
they align
medical
with
records,
current
diagnostic
coding
reports).
standards
(ICD-10,
CPT).

- Claims
- Claim Aging
Tracking Report
System: Review:
Implemen Review
t a claims the aging
tracking report to
system to identify
monitor claims
the status that have
of all not been
claims. followed
up.

Ensure
timely
Delayed
follow-up
or
and
insufficie
resolution Claims
nt follow- Medium
of denied Manager
up on
claims to
denied
recover
claims.
lost
revenue.
 -
- Follow-
Dedicate
Up Audit:
d Follow-
Sample a
Up Team:
batch of
Ensure Establish
denied
timely a team
Delayed claims
follow-up responsibl and check
or e for
and if proper
insufficie
resolution following follow-up Claims
nt follow- Medium
of denied up on actions Manager
up on
claims to denied or were
denied
recover unpaid taken.
claims. claims.
lost
revenue.

- Claims
Rework
Tracking:
- Regular
Review
Reviews:
the
Set up
rework
monthly
logs for
reviews
denied
of
claims
outstandi
and
ng claims
ensure
with
resolution
dedicated
efforts
ownershi
were
p.
timely
and
complete.
 - Daily - Cash
Reconcili Flow
ation: Analysis:
Implemen Audit the
t daily cash flow
reconciliat and
ion of collection
billed s against
services revenue
and and
payments billing
received. data.

- -
Collection Outstandi
Follow- ng
Ensure Up Balances
timely Procedur Review:
Delayed collection es: Review
collection of Establish outstandi
s from payments a ng
Collection patients from standard balances Collection
High
s or patients operating for Team
insurance and procedur overdue
companie insurers e (SOP) collection
s. to avoid for s and
revenue collection identify
loss. follow- any
ups based breakdow
on aging n in
reports. follow-up.
 -
-
Complian
Collection
ce Test:
Targets:
Check if
Set
collection
collection
procedur
targets
es are
for each
being
departme
followed
nt and
according
monitor
to
performa
hospital
nce.
policy.

- Cash
Deposit
- Cash
Audit:
Handling
Review
Procedur
cash
es:
deposit
Implemen
records
t two-
and
person
compare
verificatio
them
n for all
with
cash
patient
deposits.
payment
receipts.

Minimize
risks of
Cash
cash
misappro
mismanag
priation
ement by
during
limiting Cashier/
manual
High cash Finance
collection
handling Team
(e.g.,
and
patient
promotin
payments
g digital
in cash).
payment
systems.
 - Check
- Digital
for
Payment
Payment
Systems:
Gaps:
Minimize Encourag Investigat
risks of e patients
Cash e any
cash to make
misappro discrepan
mismanag payments cies
priation
ement by using between
during
limiting digital payments Cashier/
manual methods
High cash collected Finance
collection
handling (e.g., and Team
(e.g., credit/de
and recorded
patient
promotin bit card, in the
payments
g digital online financial
in cash).
payment transfers). system.
systems.

- Audit
System:
-
Verify the
Reconcili
functional
ation of
ity and
Cash:
usage of
Daily
digital
reconciliat
payment
ion of
systems
cash
to ensure
payments
all
against
payments
receipts.
are
recorded.
 -
- Inventory
Automate vs. Sales
d Billing: Reconcili
Use ation:
automate Compare
d inventory
dispensin usage
g systems with sales
that link records to
sales and identify
inventory. discrepan
cies.

Ensure - Theft
Unrecord that all Investigat
ed or pharmacy - ion:
mismana transactio Inventory Review
ged ns are Audits: audit
pharmacy accuratel Perform trails for
regular any Pharmacy
Pharmacy sales High y
(e.g., recorded physical unusual Manager
stock and inventory pharmacy
theft, inventory audits. stock
unbilled is movemen
sales). properly t.
managed.

- Audit
-
Sales
Segregati
Process:
on of
Check the
Duties:
billing
Separate
records
the roles
for a
of
sample of
dispensin
prescripti
g and
ons and
billing to
confirm
avoid
the sales
conflicts
were
of
recorded
interest.
properly.
 - Margin
Test:
- Margin
Check a
Review:
sample of
Conduct
invoices
regular
for proper
reviews
markup
of the
and
margin
pricing
applied to
based on
medicatio
the
ns.
charge
Ensure master.
Incorrect
correct
applicatio
pricing
n of profit
and
margins Pharmacy
markup
on Medium /Finance
are
medicines Team
applied to
leading to
all
revenue
pharmace - - Override
loss.
uticals. Approval Audit:
Workflow Investigat
for e
Overrides instances
: Ensure where
that margin
margin adjustme
adjustme nts were
nts applied
require and check
manageri for
al approvals
approval. .
 - Test
- Test Log
Logs:
vs. Billing:
Implemen
Review a
t an
sample of
electronic
diagnostic
test log
logs and
system to
compare
record
them to
every
correspon
diagnostic
ding
test
billing
performe
records.
d.

Ensure
that all
Tests - Unbilled
diagnostic
performe Tests
tests and
d but not
Diagnosti services - Daily Investigat Diagnosti
billed due High Reconcili ion:
cs are cs Team
to human ation: Identify
properly
or system
recorded Daily any
errors. reconciliat diagnostic
and
billed. ion tests
between performe
diagnostic d but not
test logs billed,
and and
billing analyze
records. reasons
for non-
billing.

- System
Alerts:
Set up
alerts for
unbilled
diagnostic
services.
 - Discount
Approval
-
Review:
Approval
Audit a
Workflow
sample of
:
discounts
Implemen
provided
t an
on
approval
diagnostic
process
services
for
Ensure to ensure
discounts
that all complianc
on
discounts diagnostic e with
Discounts on approval
services.
on diagnostic procedur
diagnosti services es. Billing
c services Medium are Superviso
not authorize r
authorize d
d. according
to
hospital
policy.

- Discount
- System
Reporting
Testing:
: Maintain
Test the
a report
system’s
on all
ability to
discounts
enforce
granted
discount
and the
approval
justificati
workflow
on for
s.
each.
 - Audit
Surgical
- Surgical
Logs:
Logs:
Cross-
Maintain
check a
detailed
sample of
records of
surgical
all
logs
surgeries,
against
including
billing
implants
records
and
for
consuma
complete
bles used.
ness and
accuracy.

-
Ensure Reconcili
Unbilled
that all ation of
surgical - Implant
surgical OR Logs
procedur Billing:
Operating procedur with OR
es, Verify
Room High es and Billing: Coordinat
implants, that all
(OR) consuma Ensure or
or implants
bles are that
consuma and
accuratel surgical
bles. consuma
y billed. logs are
bles are
reconcile
properly
d with
recorded
billing
and
records
billed.
immediat
ely post-
surgery.
 -
Reconcili
ation
Test:
Reconcile
surgical
case logs
with
billed
amounts.

-
- Check-In
Consultat
System:
ion Billing
Use an
Review:
electronic
Audit
check-in
outpatien
system to
t visits
track all
and
outpatien
follow-
t
ups for
Unbilled Ensure all consultati proper
follow-up consultati ons. billing.
consultati ons are
ons or billed
free appropria
Consultat Outpatien
consultati Medium tely and
ions t Team
ons in
provided accordanc
without e with
document hospital - Follow- - Policy
ation. policies. Up Visit Complian
ce:
Tracking:
Review
Ensure
complianc
that
e with
follow-up
policies
visits are
regarding
captured
free
and billed
consultati
according
ons or
to policy.
discounts.
 - System - System
Audits: Testing:
Perform Test the
routine billing
checks on system
the billing with real-
system world
for errors, scenarios
glitches, to ensure
and proper
Ensure misconfig functional
that the urations. ity.
IT
System systems
bugs are
causing working IT
IT
underbilli High effectivel Departme
Systems
ng or y to nt
unbilled prevent
services. underbilli - Review
ng or IT Logs:
missed - Data
Analyze
services. Integrity logs for
Checks:
any
Regular
unauthori
checks for
zed
data
access,
integrity
edits, or
and
system
accuracy
errors
across all
that could
billing
result in
modules.
revenue
leakage.
 -
- Monthly Managem
Revenue ent
Reviews: Review:
Conduct Audit
monthly meeting
revenue minutes
cycle to ensure
meetings monthly
Ensure to review revenue
managem revenue reviews
ent is performa are
Weak continuou nce. happenin
monitorin sly g.
g and monitorin
Governan oversight g key
High Mana
ce of performa
revenue- nce
related indicators
metrics. (KPIs)
related to - KPI
revenue - KPI Monitori
leakage. Dashboar ng:
ds: Use
Ensure
visual
KPIs are
dashboar
being
ds to
tracked,
track
reported,
revenue-
and acted
related
upon
KPIs in
effectivel
real-time.
y.
 Risk
Process Risk Control Objective
Impact

Ensure complete and

Incomplete or incorrect patient data
Registration & Admission High accurate patient data is
(e.g., demographics, insurance details).
captured.

Minimize denied claims by

Failure to verify insurance eligibility verifying insurance
High
before admission. coverage before service
delivery.

Unrecorded services or procedures Ensure all services provided

Billing High
provided but not billed. are captured and billed.
 Unrecorded services or procedures Ensure all services provided
Billing High
provided but not billed. are captured and billed.

Ensure accurate pricing and

Incorrect pricing or discount application. Medium
authorized discounts.

Ensure claims are accurate

Submission of incomplete or incorrect
Claims Management High and submitted with proper
insurance claims.
documentation.
 Delayed follow-up on denied or pending Ensure timely follow-up and
Medium
claims. resolution of claims issues.

Delayed collection of dues from patients Ensure timely and complete

Collections High
or insurance companies. revenue collection.

Cash misappropriation during manual Minimize risk of cash

High
collection. handling losses.
 Cash misappropriation during manual Minimize risk of cash
High
collection. handling losses.

Ensure all pharmacy

Unrecorded or mismanaged pharmacy
Pharmacy High transactions are accurately
sales (e.g., theft, manual errors).
recorded.

Ensure margins comply with

Incorrect application of profit margins on
Medium policy and are consistently
medicines.
applied.
 Ensure all diagnostic
Tests conducted but not billed due to
Diagnostics High services are recorded and
human or system errors.
billed.

Ensure compliance with

Discounts on diagnostics not authorized. Medium discount authorization
policies.

Ensure all surgeries and

Missing billing for surgical procedures or
Operating Room (OR) High consumables are captured
consumables.
and billed accurately.
 Ensure all surgeries and
Missing billing for surgical procedures or
Operating Room (OR) High consumables are captured
consumables.
and billed accurately.

Free or follow-up consultations not billed Ensure compliance with

Consultations Medium
despite policy. consultation billing policies.

System bugs causing underbilling or Ensure billing system

IT Systems High
unbilled services. accuracy and data integrity.
 Strengthen accountability
Weak monitoring and oversight of
Governance High and monitoring to minimize
revenue-related metrics.
revenue leakage.
 Control Activities Audit Test Steps

- Check a sample of patient

- Verify patient ID and insurance details. registrations for
completeness.

- System prompts for mandatory fields - Review rejected claims

during registration. due to registration errors.

- Examine a sample of
admissions to confirm
eligibility checks.

- Conduct insurance eligibility checks prior

to admission.

- Review denied claims

reports for eligibility-
related issues.

- Compare a sample of
service logs to billing data.

- Reconcile service logs (doctors' orders,

diagnostics) with billing records.
- Reconcile service logs (doctors' orders,
diagnostics) with billing records.

- Investigate discrepancies
and reasons for missing
billing entries.

- Implement system-based pricing and - Test pricing accuracy on a

discount authorization workflows. sample of bills.

- Review discount
- Periodic tariff updates. approvals for compliance
with policy.

- Analyze rejected claims

- Conduct pre-submission reviews of for trends
insurance claims. (coding/documentation
errors).

- Maintain detailed records for every - Verify if claims corrections

claim. were followed up.
 - Review aging reports for
- Establish a claims tracking system.
pending claims.

- Examine follow-up notes

- Assign ownership for follow-up actions. for denied claims to ensure
timely action.

- Perform reconciliation
- Reconcile daily billing and collection
between billing, collections,
reports.
and outstanding balances.

- Establish follow-up procedures for - Verify adherence to

overdue balances. follow-up protocols.

- Test cash collection

- Limit cash transactions by promoting
records against deposit
digital payments.
slips.
- Implement cash-handling controls (e.g., - Review compliance with
two-person verification). cash-handling policies.

- Compare inventory
- Automate pharmacy billing. changes with pharmacy
sales reports.

- Investigate discrepancies
- Regular stock audits and reconciliation
in stock and sales
with sales records.
reconciliation.

- Periodic reviews of profit margin setups - Test pricing accuracy for a

in the system. sample of medicines.

- Review margin override

- Approvals for margin overrides.
logs and approvals.
- Reconcile diagnostic logs with billing - Compare a sample of test
records. logs with billing data.

- Cross-check system-based logs for - Investigate reasons for

discrepancies. unbilled tests.

- Review discounts
provided for compliance
with approval policy.

- Maintain approval workflow for

discounts in the billing system.

- Test the effectiveness of

the approval workflow in
the system.

- Compare surgery
- Reconcile surgery logs with billing data. schedules with billing
records.
 - Review implant usage
- Track usage of high-value implants. documentation against
bills.

- Review a sample of
- Implement a patient check-in system for
outpatient logs to check
consultations.
billing compliance.

- Verify adherence to
- Track follow-up visits for billing accuracy. policies for free and follow-
up consultations.

- Test the system with

- Conduct regular audits of the billing
known scenarios to check
system.
accuracy.

- Review access logs for

- Restrict unauthorized access to billing
unauthorized edits or
software.
anomalies.
 - Review meeting minutes
- Monthly revenue and leakage reports.
on revenue reviews.

- Assess the effectiveness

- Assign accountability to department of corrective actions taken
heads for revenue targets. for identified leakage
points.
 Responsible Party

Registration Staff

Registration & Billing Team

Billing Team
Billing Team

Billing Supervisor

Claims Team
Claims Manager

Collection Team

Cashier/Finance Team
Cashier/Finance Team

Pharmacy Manager

Pharmacy/Finance Team
Diagnostics Team

Billing Supervisor

OR Coordinator
OR Coordinator

Outpatient Team

IT Department
Management