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THE ROLE OF THE MEDICAL ACCOUNTS AUDITOR IN THE FINANCIAL RISK MANAGEMENT OF HEALTHCARE INSTITUTIONS
Objective. To describe the role of medical claims auditing in financial risk management within healthcare institutions, highlighting its contribution to economic sustainability, spending efficiency, and quality of care delivery. Methodology. A conceptual and descriptive analysis is presented of the medical claims audit process and the functions of the auditor, considering their impact on invoice verification, prevention of improper payments, reduction of recurrent denials, and generation of information for financial planning and decision-making. Results.
Medical claims auditing is identified as a strategic pillar that prevents improper payments, reduces recurrent denials, protects cash flow, and improves relationships between providers and payers. It also supplies key inputs to project expenditures, detect budget deviations, and design cost-containment strategies, thereby strengthening hospital sustainability in low-margin environments. Within this framework, the medical claims auditor emerges as a strategic actor who promotes transparency, rational use of resources, and continuity in the provision of quality health services. Conclusion. Medical claims auditing constitutes a comprehensive management tool for protecting health system resources and consolidating stronger, more efficient institutions oriented both to the patient and to organizational goals. Its proper implementation contributes to reducing financial loss ratios and to strengthening sustainable care models grounded in evidence-based decision-making.
