CHC Auditing and Monitoring 4 — Questions and Answers
Question 1: What is the purpose of a 'baseline audit' in a newly established healthcare compliance program?
- To fulfill a mandatory federal reporting requirement at program inception
- To establish a benchmark of current compliance status against which future audits can be measured (Correct answer)
- To identify staff members who need immediate disciplinary action
- To replace the annual risk assessment process
Correct answer: To establish a benchmark of current compliance status against which future audits can be measured
A baseline audit establishes the organization's starting compliance posture, creating a benchmark to measure improvement from future auditing and monitoring efforts.
Question 2: Which of the following is an example of a 'red flag' that might trigger a reactive compliance audit?
- Receipt of an OIG advisory opinion
- A whistleblower complaint alleging systematic billing fraud (Correct answer)
- Publication of the annual OIG Work Plan
- Renewal of the compliance officer's certification
Correct answer: A whistleblower complaint alleging systematic billing fraud
A whistleblower complaint alleging systematic billing fraud is a specific trigger that warrants an immediate reactive audit to investigate the claim.
Question 3: In healthcare compliance auditing, what does 'two-sided testing' refer to?
- Auditing both the clinical and financial aspects of a record simultaneously
- A statistical hypothesis test that checks for deviation in either direction from the expected value (Correct answer)
- Reviewing claims from two different payers in the same audit
- Conducting both internal and external audits of the same records
Correct answer: A statistical hypothesis test that checks for deviation in either direction from the expected value
Two-sided (two-tailed) statistical testing checks whether the observed error rate is significantly higher or lower than expected, not just in one direction.
Question 4: A compliance audit of E/M coding reveals that 80% of visits are coded at the highest level of service. What is the MOST likely compliance concern?
- Undercoding due to inadequate documentation training
- Upcoding, where services are billed at a higher complexity level than documented (Correct answer)
- Appropriate coding reflecting a high-acuity patient population
- A data entry error in the billing system
Correct answer: Upcoding, where services are billed at a higher complexity level than documented
A bell curve distribution of E/M codes is expected; clustering at the highest level suggests upcoding, where services are billed at a higher complexity than documentation supports.
Question 5: What is a 'corrective action plan' (CAP) in the context of a compliance audit?
- A legal agreement with the OIG to resolve identified violations
- A documented set of steps to address and remediate findings identified during an audit (Correct answer)
- An appeal submitted to CMS disputing audit findings
- A training schedule for new compliance department hires
Correct answer: A documented set of steps to address and remediate findings identified during an audit
A CAP is a written plan outlining specific actions, responsible parties, and timelines to correct deficiencies identified during a compliance audit.
Question 6: Which of the following BEST describes the concept of 'risk-based auditing'?
- Auditing only high-risk patients' medical records
- Allocating audit resources to areas with the greatest potential for non-compliance or financial harm (Correct answer)
- Avoiding auditing low-volume service lines to reduce costs
- Auditing only claims that have been denied by payers
Correct answer: Allocating audit resources to areas with the greatest potential for non-compliance or financial harm
Risk-based auditing prioritizes areas that pose the greatest compliance risk, focusing limited resources where they will have the most impact.
Question 7: When conducting a medical record audit, what does 'legibility' of documentation primarily affect from a compliance perspective?
- The ability of auditors to verify that services were documented and support the billed code (Correct answer)
- The speed at which auditors can complete their review
- The organization's HIPAA privacy compliance
- The accuracy of ICD-10 code assignment by coders
Correct answer: The ability of auditors to verify that services were documented and support the billed code
Illegible documentation prevents auditors from verifying that services billed were actually rendered and properly supported, creating a compliance and reimbursement risk.
CHC Auditing and Monitoring 4
What is the purpose of a 'baseline audit' in a newly established healthcare compliance program?