Patient registration, admission and discharge
Risk: Patient records, admission approvals, discharge summaries or billing handoffs are incomplete, causing revenue leakage and weak medical-record evidence.
Controls
- UHID and admission controls
- Package/estimate approval
- Discharge checklist
- Medical-record completion tracker
Tests
- Sample admissions for UHID, consent and estimate approval
- Match discharge summary to final bill and insurance file
- Review delayed discharge-to-bill handoffs
- Trace missing records to closure
Evidence
UHID record, admission form, consent, estimate, discharge summary, final bill, medical-record tracker and closure evidence.
Patient billing and package controls
Risk: Services, room rent, procedures, implants or consumables are omitted, miscoded, discounted or billed outside approved tariff/package terms.
Controls
- Approved tariff master
- Package configuration review
- Billing cut-off checklist
- Discount and waiver approval
Tests
- Reconcile procedure notes, OT register and diagnostics to billing
- Test tariff/package master changes
- Review discounts, write-offs and bill reversals
- Check discharge cut-off completeness
Evidence
Tariff master, package master, bill register, OT/procedure notes, diagnostics order, discount approval and final bill.
TPA, insurance and government-scheme claims
Risk: Claims are rejected, short-settled, duplicated, delayed or booked without matching patient/service evidence.
Controls
- Pre-authorisation tracker
- Claim submission checklist
- Denial management review
- Claim-to-receipt reconciliation
Tests
- Match sampled claims to pre-authorisation, final bill and discharge file
- Age rejected and short-settled claims
- Reconcile receipts to claim ledger
- Review duplicate or resubmitted claims
Evidence
Pre-authorisation, claim file, discharge summary, bill, insurer/TPA portal status, denial log, settlement advice and bank receipt.
Pharmacy, implants and medical consumables
Risk: Medicines, implants or consumables are issued, returned, expired, substituted or written off without accurate billing and stock evidence.
Controls
- GRN and batch tracking
- Issue-to-patient billing control
- Return and expiry review
- High-value implant approval
Tests
- Match pharmacy/implant issues to patient bills
- Review expiry and near-expiry stock
- Test returns, write-offs and substitutions
- Reconcile high-value implant purchase to use and billing
Evidence
GRN, batch ledger, pharmacy issue slip, patient bill, return note, expiry report, implant register and approval trail.
OT, procedure, diagnostics and lab revenue
Risk: OT, diagnostics, lab, radiology or procedure services are performed but not billed, billed late or billed under the wrong package.
Controls
- Order-to-service-to-bill matching
- OT/procedure register review
- Diagnostics interface reconciliation
- Cancellation approval
Tests
- Reconcile OT register to patient bills
- Match lab/radiology orders to completed tests and invoices
- Review cancelled tests and procedure reversals
- Test interface exceptions
Evidence
OT register, procedure notes, lab/radiology order, test completion report, billing extract, cancellation log and interface report.
Doctor payouts, referral fees and consultant contracts
Risk: Consultant payouts, retainers, revenue share, incentives or referral arrangements are computed incorrectly or outside approved contracts.
Controls
- Approved consultant contract
- Payout computation review
- Referral/marketing policy
- TDS and GST review
Tests
- Recompute selected doctor payouts against contract terms
- Match procedure revenue to payout base
- Review manual adjustments and exceptions
- Tie TDS/GST treatment to payout support
Evidence
Consultant contract, payout working, procedure revenue report, adjustment approval, TDS working, GST invoice/support and payment proof.
Cash, deposits, refunds and receivables
Risk: Patient deposits, cash collections, refunds, credit bills or old receivables are not reconciled or authorised.
Controls
- Daily cash count
- Deposit ledger review
- Refund approval matrix
- Receivables ageing review
Tests
- Reconcile cash/card/UPI receipts to bills and bank
- Test patient deposit adjustments and refunds
- Age credit bills and TPA receivables
- Review write-offs and waivers
Evidence
Cash count, receipt register, bank statement, patient deposit ledger, refund note, ageing report, write-off approval and waiver support.
Biomedical equipment, capex and maintenance
Risk: Medical equipment, AMC/CMC, calibration, downtime, capex or asset tagging is not controlled, affecting service continuity and asset records.
Controls
- Capex approval
- Asset tagging
- AMC/CMC tracker
- Calibration and downtime log
Tests
- Match biomedical asset register to physical equipment
- Review calibration and preventive maintenance status
- Test capex approvals and capitalisation
- Inspect downtime and service reports
Evidence
Capex approval, invoice, installation report, fixed asset register, asset tag, AMC/CMC contract, calibration certificate and downtime log.
Compliance, patient data and ITGC
Risk: Licences, statutory registers, HIS access, billing master changes or patient-data access are not controlled or evidenced.
Controls
- Licence and compliance calendar
- HIS role-based access
- Billing master change approval
- Audit-log review
Tests
- Review licence/compliance tracker and renewals
- Test HIS/POS users, leavers and privileged access
- Sample billing/tariff master changes
- Inspect audit logs for sensitive patient/billing activity
Evidence
Licence tracker, statutory returns, HIS user list, role matrix, leaver list, master change log, UAT approval and audit-log extract.
