Risk Analysis & Communication Flashcards
Which statement is TRUE regarding an audit report?
a. Do not overstate potential risks (for example, by suggesting that documentation or coding mistakes are fraudulent or will land the provider in jail).
b. The report should be written in legal language regardless of how easy it is to understand to protect the auditor.
c. It is not necessary to be objective as long as the provider understands the risks involved.
d. The report should be as lengthy as possible in an attempt to validate
a. Do not overstate potential risks (for example, by suggesting that documentation or coding mistakes are fraudulent or will land the provider in jail).
Who regulates TriCare?
TriCare is for service members and retirees and is regulated by the Department of Defense.
What type of information can be found in the provider’s contract with the insurance carrier?
a. Potential risks to specific providers.
b. Utilization patters of the provider compared to all other providers of the same specialty in that region.
c. The provider’s obligation to follow the insurance company’s medical policies.
d. The insurance benefits for each patient covered by that carrier.
c. The provider’s obligation to follow the insurance company’s medical policies.
Under the reverse false claims provision of the False Claims Act, what must be understood by an auditor?
a. Declaring an audit error without binding standards can inappropriately expose the audited provider to FCA liability.
b. An auditor’s results do not have any effect under the FCA.
c. Any audit findings should be reported to the appropriate carrier under the FCA.
d. Declaring an audit error based on non-binding standards identifies more risk areas and protects the provider further under the FCA.
a. Declaring an audit error without binding standards can inappropriately expose the audited provider to FCA liability.
Which option represents information that may be found in a contract between a provider and a commercial insurance plan that is pertinent to an auditor?
a. Whether the provider is required to report the nurse to doctor ratio for the clinic.
b. Whether the provider is required to disclose when new employees are hired.
c. Whether the provider is obligated to conform to the insurance company’s published medical policies.
d. Whether the provider is required to perform annual audits of their
c. Whether the provider is obligated to conform to the insurance company’s published medical policies.
What is a rebuttal audit?
An audit in response to a payer audit, in which the auditor is tasked with validating or refuting the conclusions of the payer audit.
Which audit example below represents a prospective audit?
a. An audit based on a payer downcoding E/M levels on EOBs.
b. An audit based on bundling issues identified on EOBs.
c. An audit to evaluate if a provider’s documentation supports ICD-10-CM coding.
d. A focused audit based on denials from an insurance carrier.
c. An audit to evaluate if a provider’s documentation supports ICD-10-CM coding.
What provides an entity the ability to self-disclose potential instances of fraud involving federal healthcare programs for which liability arises under the Civil Monetary Penalty Law?
OIG Self Disclosure Protocol (SDP)
Which statement is TRUE regarding the recommendations section of an audit report?
a. The recommendations section should contain recommendations for resolving any detected errors.
b. The recommendations section should include details of each claim affected by the errors detected during the audit.
c. The order of the recommendations is irrelevant as long as they are all listed.
d. If there are no binding rules for the post-payment risks detected, they should not be included in the recommendation
a. The recommendations section should contain recommendations for resolving any detected errors.
How long is a Corporate Integrity Agreement (CIA) usually in force?
Five years
Of the examples below, which may require an auditor to identify non-standard coding and reimbursement rules?
a. Commercial insurance carriers
b. Auto and Workers’ Compensation
c. Medicare plans
d. Medicaid plans
b. Auto and Workers’ Compensation
What should the writing style of an audit report be?
Persuasive
What is the reason audit findings should be discussed with the audited provider?
a. To identify abuse areas before providing the information to Medicare.
b. To identify areas where the provider has committed fraudulent activities before providing the information to the OIG.
c. To become friends with the provider so he will hire you as an auditor resource again.
d. To provide a risk analysis, identify problem areas, and recommend corrective action with supporting documentation.
d. To provide a risk analysis, identify problem areas, and recommend corrective action with supporting documentation.
What act would be considered a False Claims Act (FCA) violation under what is known as the “reverse false claims provision” of the FCA?
a. Reporting two services together that were identified as bundled by NCCI.
b. Reporting a higher level of E/M code than is supported by the documentation.
c. Reporting more units than allowed by MUE.
d. Failure to refund an overpayment.
d. Failure to refund an overpayment.
Rationale: Where errors result in mere overpayments for which there was no evidence of fraudulent conduct, an entity must “voluntarily” identify, disclose, and refund overpayments as detailed above to avoid a violation of the False Claims Act (FCA) liability under what is known as the “reverse false claims provision” of the FCA.
What type of insurance carrier might be considered a state regulated commercial insurance plan?
a. Medicare
b. Aetna
c. TriCare
d. Workers’ Compensation
D. Workers’ Compensation
Rationale: State regulated insurance plans are most commonly found associated with first party medical claims in an auto insurance case (where the state law requires or provides for such coverage) or workers’ compensation claims.
