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 purpose of a 'baseline audit' in a newly established healthcare compliance program?
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.
Which of the following is an example of a 'red flag' that might trigger a reactive compliance audit?
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.
In healthcare compliance auditing, what does 'two-sided testing' refer to?
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.
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?
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.
What is a 'corrective action plan' (CAP) in the context of a compliance audit?
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.
Which of the following BEST describes the concept of 'risk-based auditing'?
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.
When conducting a medical record audit, what does 'legibility' of documentation primarily affect from a compliance perspective?
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.