Concurrent audit: a checklist for the hospital stay

Concurrent audit is carried out during the patient’s hospital stay, while care is still under way. Unlike retrospective audit, which reviews the claim after discharge, concurrent audit makes it possible to identify and correct discrepancies as they happen: a procedure recorded incorrectly, a material entered without support in the prescription, a daily rate charged under the wrong code.

For the hospital, this affects billing. Every discrepancy corrected during the hospital stay is a denial avoided on the final claim. As a result, concurrent audit can reduce the volume of post-submission disputes and speed up the payment cycle.

The starting point for structuring this process is knowing what to check, when and by what criteria. This checklist brings together the main points of attention in concurrent audit, organized by category, to support audit and billing teams in the hospital routine.

What concurrent audit is and what the regulations say

Concurrent audit is the form of hospital auditing carried out in real time, during the hospital stay, with direct access to the medical record, the care team and the patient’s clinical information. Its goal is to verify the quality and appropriateness of the care provided and to identify inconsistencies in the recording of procedures, materials and services before the claim is closed.

In private healthcare, the main regulatory milestone on the subject is ANS (Brazil’s National Supplementary Health Agency) Normative Resolution No. 507/2022, which provides for the Accreditation Program for Private Health Plan Operators, establishing concurrent audit as a requirement of the program and recognizing its role in improving care and controlling the use of resources.

It is worth noting that CFM (Federal Council of Medicine) Resolution No. 1,614/2001, which regulates the types of medical audit, provides only for the prospective and retrospective forms, without addressing real-time auditing. For the provider hospital, this context reinforces the need to structure internal auditing during the hospital stay, with qualified professionals and documented processes.

Why concurrent audit protects the hospital’s revenue

In the hospital routine, recording errors happen during the hospital stay: a procedure performed without an update to the medical record, a material used without being entered on the claim, a clinical progress note that would justify charging a fee and was not documented in time. When these errors reach retrospective audit, some of them are already unrecoverable, either because of the correction deadline or because there is no clinical evidence made at the time of care.

Concurrent audit works precisely in this window. With real-time access to the medical record, the auditor can flag inconsistencies to the care team while it is still possible to correct the record, complete the documentation or technically justify the charge. The result is a more accurate claim, with a lower denial rate and less need for appeals after submission.

This process does not replace but complements prospective audit, which works on the pre-authorization of procedures. Together they form a control cycle that covers the three critical phases of billing: before, during and after the hospital stay.

What should be checked during the hospital stay

The items below are organized by the categories with the highest incidence of discrepancies on the hospital claim.

Clinical documentation and medical record

• Medical record updated with physician and nursing progress notes at a frequency consistent with the type of stay.

• Record of all medical prescriptions with a legible, dated clinical indication.

• Consistency between the recorded diagnosis and the procedures, tests and medications prescribed.

• Test reports attached and linked to the corresponding request.

• Record of complications and the actions taken during the hospital stay.

Procedure compliance with the authorization

• Checking whether the procedures performed are within the scope of the authorization issued by the payer.

• Identifying procedures performed without prior authorization that require immediate notification to the payer

• Consistency between the TUSS code of the procedures performed and the authorized codes

• Record of clinical justification for high-cost procedures or those outside the usual protocol

Materials and medications

• Reconciling the materials and medications prescribed, administered and entered on the claim.

• Checking for duplicate entries, especially at shift changes.

• Consistency between the presentation of the medication prescribed and the one charged (dosage, route of administration, frequency).

• Identifying OPME (implants and special materials) used, with invoice records and implant traceability.

Daily rates and fees

• Checking the type of daily rate charged against the patient’s level of care (ward, private room, ICU, step‑down unit).

• Consistency between the length of stay recorded and the length billed.

• Checking operating room, recovery and special procedure fees against a record that they were performed in the medical record.

Care team records

• Identification and recording of all professionals who took part in the care, with their CRM or COREN number.

• Checking surgical team fees for consistency between the professionals present and those charged.

• Record of the participation of the anesthesiologist, assistants and scrub technicians when applicable.

How to structure the concurrent audit process in the hospital

Applying the checklist depends on a minimally structured process. Without defined responsibilities, frequency and prioritization criteria, concurrent audit tends to be fragmented, covering only the most visible cases and leaving systematic gaps in hospital stays of lower apparent complexity.

The central professional in this process is the nurse auditor, with the clinical training to interpret the medical record and identify recording and billing inconsistencies. In hospitals with a high volume of admissions, mixed teams of nurses and billing technicians make it possible to separate clinical verification from administrative verification, increasing coverage without compromising the quality of the review.

The frequency of verification should be defined by risk criteria, not by team availability. ICU stays, major surgeries, use of OPME and oncology treatments require daily audits, given the complexity and volume of billable items. Lower-complexity clinical stays allow for checks every 48 or 72 hours, with a mandatory review in the 24 hours before discharge.

The moment of discharge is critical: it is the last opportunity to check whether the claim faithfully reflects everything that was done during the hospital stay, correct pending entries and make sure the supporting documentation is complete before submission to the payer.

Concurrent audit and the use of technology

Each item corrected during the hospital stay represents a denial that is not generated, an appeal that is no longer needed and a deadline that no longer needs to be tracked. The effort of correcting in real time is consistently smaller than the effort of disputing after the claim is submitted.

Rivio applies artificial intelligence to audit 100% of hospital claims directly from the ERP, automatically identifying entry errors, discrepancies and missing items before they become denials, with oversight from billing specialists at every stage of the process.

Frequently asked questions about concurrent audit

What is concurrent audit in hospitals?

Concurrent audit is the form of audit carried out during the patient’s hospital stay, in real time. Its goal is to verify the quality of the care provided and identify inconsistencies in the recording of procedures, materials and services before the hospital claim is closed.

What is the difference between concurrent audit and retrospective audit?

Concurrent audit takes place during the hospital stay, while it is still possible to correct records and complete documentation. Retrospective audit is carried out after the patient’s discharge, before the claim is sent to the payer. The two forms are complementary: concurrent audit reduces discrepancies at the source; retrospective audit performs the final review before submission to the payer.

Who can perform concurrent audit in the hospital?

The nurse auditor is the central professional in this process, with the clinical training to interpret the medical record and identify recording and billing inconsistencies. In hospitals with a higher volume of admissions, mixed teams of nurses and billing technicians make it possible to expand audit coverage.

Is concurrent audit mandatory?

ANS Normative Resolution No. 507/2022, which provides for the Accreditation Program for Private Health Plan Operators, establishes concurrent audit as a requirement of the program. For provider hospitals, structuring internal concurrent audit is a management practice, with a direct impact on reducing denials and protecting revenue.

How does concurrent audit reduce denials?

By identifying discrepancies during the hospital stay, concurrent audit makes it possible to correct records, complete documentation and justify charges while the clinical evidence is still available. This reduces the volume of inconsistencies that reach the final claim and, consequently, the number of denials generated by the payer after submission.