CHC Auditing and Monitoring 2 — Questions and Answers
Question 1: What is the primary distinction between auditing and monitoring in a healthcare compliance program?
- Auditing is a retrospective, periodic review while monitoring is ongoing and real-time (Correct answer)
- Monitoring is conducted by external parties while auditing is done internally
- Auditing covers clinical quality while monitoring covers billing only
- Monitoring requires board approval while auditing does not
Correct answer: Auditing is a retrospective, periodic review while monitoring is ongoing and real-time
Auditing is a retrospective, in-depth periodic review of past activities, whereas monitoring is a continuous, ongoing process to track compliance in real time.
Question 2: Which statistical sampling method selects every nth record from a population and is commonly used in compliance audits?
- Random sampling
- Systematic sampling (Correct answer)
- Stratified sampling
- Cluster sampling
Correct answer: Systematic sampling
Systematic sampling selects every nth item from a list, making it easy to implement in claim or medical record audits.
Question 3: Under the OIG's guidance, what minimum sample size is generally recommended for an effective baseline audit?
- 10 records
- 25 records (Correct answer)
- 50 records
- 100 records
Correct answer: 25 records
The OIG generally recommends a minimum of 25 records for a baseline audit to obtain statistically meaningful results.
Question 4: A compliance officer discovers a pattern of upcoding in physician billing. Which type of audit should be initiated first?
- Proactive scheduled audit
- Reactive focused audit (Correct answer)
- External third-party audit
- Random baseline audit
Correct answer: Reactive focused audit
A reactive focused audit is triggered by a specific concern or identified risk, such as a pattern of upcoding, to investigate the issue promptly.
Question 5: What does an 'error rate' represent in a healthcare compliance audit?
- The percentage of denied claims in a billing cycle
- The proportion of audited records found to be non-compliant or inaccurate (Correct answer)
- The number of compliance violations reported annually
- The frequency of coding corrections made by coders
Correct answer: The proportion of audited records found to be non-compliant or inaccurate
The error rate is the proportion of records in the sample that contain inaccuracies or non-compliance, used to extrapolate issues across the entire population.
Question 6: Which federal law requires healthcare organizations to have compliance programs including auditing and monitoring as a condition of enrollment in federal healthcare programs?
- HIPAA
- Stark Law
- The Affordable Care Act
- Social Security Act Section 6401 (Correct answer)
Correct answer: Social Security Act Section 6401
Section 6401 of the Affordable Care Act, codified under the Social Security Act, requires certain providers to have compliance programs as a condition of enrollment in Medicare and Medicaid.
Question 7: When an audit reveals overpayments from a federal healthcare program, within how many days must the overpayment be reported and returned under the 60-day rule?
- 30 days from identification
- 60 days from identification (Correct answer)
- 90 days from identification
- 120 days from identification
Correct answer: 60 days from identification
Under the 60-day rule (42 CFR § 401.305), providers must report and return identified Medicare/Medicaid overpayments within 60 days of identification.
CHC Auditing and Monitoring 2
What is the primary distinction between auditing and monitoring in a healthcare compliance program?