This healthcare audit work program is intended to determine whether internal controls in the provider contracting and capitated payment processes are in place and working effectively. It provides a comprehensive review of provider contracts, including their type, location and service provider specialty, and enables them to select a varied sample for detailed examination. It also ensures that contracts are input into the system prior to their effective date and that they have been approved by the legal department.

Furthermore, it provides guidance on examining significant contract terms such as payment methods, timing, documentation requirements and legal obligations. For capitated payment contracts, it provides a framework for validating payment amounts and tracing them back to the member count in supporting documentation. In essence, this tool offers a systematic approach to audit healthcare provider contracts, ensuring that all necessary aspects are covered, leading to a robust and thorough audit.

Project work steps include:

• Obtain a listing of all provider contracts during the periods of (Insert Date) and (Insert Date).
• Obtain a copy of the current delegation of authority for the provider relations department.
• Obtain the prior year’s documentation of the controls associated with provider contracting and capitated payment processing.
• Determine whether the company’s legal department used, approved and reviewed a standard contract boilerplate.