CHC Auditing and Monitoring 3 — Questions and Answers
Question 1: In a stratified sampling approach for a compliance audit, what is the main advantage over simple random sampling?
- It requires fewer total records to review
- It ensures proportional representation of distinct subgroups within the population (Correct answer)
- It eliminates the need for a statistical confidence interval
- It can only be performed by external auditors
Correct answer: It ensures proportional representation of distinct subgroups within the population
Stratified sampling divides the population into subgroups (strata) and samples from each, ensuring all relevant categories are represented in the audit.
Question 2: What is 'extrapolation' in the context of a Medicare compliance audit?
- Projecting the findings from a sample to estimate the error across the entire claim population (Correct answer)
- Adding additional records to an audit sample after initial review
- Comparing audit results to national benchmark error rates
- Calculating the statistical confidence level of an audit
Correct answer: Projecting the findings from a sample to estimate the error across the entire claim population
Extrapolation uses the error rate found in the sample to estimate the total overpayment or error amount across the full billing population.
Question 3: Which element is NOT typically included in a formal audit report?
- Scope and objectives of the audit
- Methodology used to select records
- Personal opinions of individual staff members (Correct answer)
- Findings and recommendations
Correct answer: Personal opinions of individual staff members
Formal audit reports are objective documents; they include scope, methodology, findings, and recommendations, but not personal opinions of staff.
Question 4: A healthcare organization's compliance monitoring program flags an unusually high rate of modifier 25 usage. What is the BEST next step?
- Immediately report the issue to the OIG
- Conduct a focused audit to determine if the modifier is being used appropriately (Correct answer)
- Retrain all billing staff without further investigation
- Suspend all claims containing modifier 25
Correct answer: Conduct a focused audit to determine if the modifier is being used appropriately
A focused audit investigates the specific flagged issue to determine root cause and whether the modifier is being appropriately applied before taking further action.
Question 5: What role does a 'work plan' serve in an OIG compliance context for healthcare organizations?
- It is the annual list of OIG audit and enforcement priorities used to guide internal compliance focus (Correct answer)
- It is a required document that all providers must submit to CMS annually
- It details the internal staffing plan for a compliance department
- It replaces the need for a written compliance policy manual
Correct answer: It is the annual list of OIG audit and enforcement priorities used to guide internal compliance focus
The OIG Work Plan identifies the areas the OIG plans to review, helping healthcare organizations prioritize their own internal auditing and monitoring efforts.
Question 6: Which of the following BEST describes 'continuous monitoring' in a compliance program?
- Annual review of all claims submitted to federal payers
- Automated, real-time or near-real-time oversight of transactions and processes for anomalies (Correct answer)
- Monthly manual review of a random sample of records
- Quarterly external audits performed by independent auditors
Correct answer: Automated, real-time or near-real-time oversight of transactions and processes for anomalies
Continuous monitoring uses automated tools to provide ongoing, real-time oversight of processes and transactions, flagging anomalies as they occur.
Question 7: Under a Corporate Integrity Agreement (CIA), what type of auditing is typically required of the organization?
- Ad hoc self-auditing based on leadership discretion
- Independent Review Organization (IRO) audits of claims and arrangements (Correct answer)
- Peer review by similar healthcare organizations
- Annual audits conducted solely by the OIG
Correct answer: Independent Review Organization (IRO) audits of claims and arrangements
CIAs typically require the organization to engage an Independent Review Organization (IRO) to conduct objective audits of claims, arrangements, or other specified areas.
CHC Auditing and Monitoring 3
In a stratified sampling approach for a compliance audit, what is the main advantage over simple random sampling?