Auditing and Monitoring Flashcards
7 cards from real CHC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Auditing and Monitoring flashcards as text
What is the primary distinction between auditing and monitoring in a healthcare compliance program?
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.
Which statistical sampling method selects every nth record from a population and is commonly used in compliance audits?
Answer: Systematic sampling
Systematic sampling selects every nth item from a list, making it easy to implement in claim or medical record audits.
Under the OIG's guidance, what minimum sample size is generally recommended for an effective baseline audit?
Answer: 25 records
The OIG generally recommends a minimum of 25 records for a baseline audit to obtain statistically meaningful results.
A compliance officer discovers a pattern of upcoding in physician billing. Which type of audit should be initiated first?
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.
What does an 'error rate' represent in a healthcare compliance audit?
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.
Which federal law requires healthcare organizations to have compliance programs including auditing and monitoring as a condition of enrollment in federal healthcare programs?
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.
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?
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.