CHC - Certified in Healthcare Compliance Auditing and Monitoring Questions and Answers — Questions and Answers
Question 1: A key distinction between auditing and monitoring within a healthcare compliance program is that auditing is typically performed by:
- An independent party, while monitoring is an ongoing operational management function. (Correct answer)
- The compliance officer, while monitoring is performed by the board of directors.
- External consultants exclusively, while monitoring is done by internal staff.
- The operational department manager, while monitoring is conducted by the compliance department.
Correct answer: An independent party, while monitoring is an ongoing operational management function.
Auditing is a formal, periodic evaluation conducted by an independent party (like internal audit or an external firm) to ensure objectivity. Monitoring consists of ongoing, routine activities conducted by management and operational staff to ensure processes are working as intended.
Question 2: A hospital's compliance officer is developing the annual audit plan. Which of the following is the most critical first step in this process?
- Reviewing the previous year's audit findings.
- Interviewing department heads about their concerns.
- Conducting a comprehensive risk assessment. (Correct answer)
- Analyzing the OIG's most recent Work Plan.
Correct answer: Conducting a comprehensive risk assessment.
A comprehensive risk assessment is the foundational element of an effective compliance program and should be the starting point for developing a risk-based audit plan. This process identifies and prioritizes the organization's specific risks, which then guides the focus of audit activities. The other options are valuable inputs to the risk assessment but are not the first or most critical step.
Question 3: During a routine internal audit of physician billing, a small sample of 10 claims for a specific high-level E/M code reveals a 30% error rate due to insufficient documentation. What is the compliance professional's BEST next step?
- Immediately report the physician to the OIG for potential fraud.
- Provide mandatory, system-wide training on E/M coding for all providers.
- Discipline the physician for failing the audit.
- Expand the audit to a statistically valid random sample to determine the scope of the problem. (Correct answer)
Correct answer: Expand the audit to a statistically valid random sample to determine the scope of the problem.
A small, non-statistical sample is not sufficient to draw conclusions about the overall error rate or financial impact. The best practice is to expand the review to a statistically valid random sample to accurately quantify the scope and magnitude of the issue before determining appropriate corrective action, such as education or repayment.
Question 4: Which of the following best describes the primary purpose of ongoing monitoring activities in a healthcare compliance program?
- To provide an annual, independent assessment of the compliance program's effectiveness.
- To satisfy the requirements of external government auditors.
- To serve as the sole basis for employee disciplinary actions.
- To detect and correct compliance issues in real-time or near real-time. (Correct answer)
Correct answer: To detect and correct compliance issues in real-time or near real-time.
Ongoing monitoring is designed to be a continuous process that allows for the early detection of potential compliance issues, enabling prompt correction before they become systemic problems. Audits, by contrast, are periodic, point-in-time assessments.
Question 5: When selecting a sample for an audit of claims, which methodology is most appropriate for ensuring that high-dollar claims are adequately represented in the review?
- Systematic sampling
- Simple random sampling
- Stratified random sampling (Correct answer)
- Convenience sampling
Correct answer: Stratified random sampling
Stratified random sampling involves dividing the entire population of claims into different subgroups, or 'strata'—in this case, by dollar value. A random sample is then taken from each stratum. This method ensures that high-risk areas, such as high-dollar claims, are included in the audit sample, providing a more targeted and risk-based review than a simple random sample might.
Question 6: According to the OIG, an effective compliance program includes auditing and monitoring as one of its seven core elements. The primary goal of this element is to:
- Guarantee the organization will pass all external government investigations.
- Evaluate the effectiveness of the compliance program and detect offenses. (Correct answer)
- Assign blame for compliance failures to specific individuals.
- Reduce the compliance department's annual budget by identifying efficiencies.
Correct answer: Evaluate the effectiveness of the compliance program and detect offenses.
The OIG's guidance on the seven elements of an effective compliance program clearly states that internal monitoring and auditing are crucial for evaluating adherence to the organization's policies, procedures, and applicable regulations, thereby assessing the program's overall effectiveness and helping to detect potential violations.
CHC - Certified in Healthcare Compliance Auditing and Monitoring Questions and Answers
A key distinction between auditing and monitoring within a healthcare compliance program is that auditing is typically performed by: