CHC Auditing & Monitoring (2) UPDATED
ACTUAL Exam Questions and CORRECT
Answers
A healthcare provider must repay to Medicare money paid for a specific type of billed claim.
What type of audit is the MOST likely one used to identify the amount of repayment? -
CORRECT ANSWER - Full statistical audit
A Physician practice are having a hard time determining which claims have been paid in full, and
which claims have not been paid at all. What test would be practical for the group to perform to
validate the claims that have been paid or not paid.
A. Statistical Sampling
B. Rat-Stats
C. Snap Shots
D. Random Sampling - CORRECT ANSWER - A. Statistical Sampling
Regarding statistical sampling, what is an example of failed efforts to use statistical analysis?
a. Users who did not understand subject matter or application of sampling.
b. A well-rounded data sample
c. Knowledgeable staff who are involved in the process
d. Investigations done of improper billing practices - CORRECT ANSWER - a. Users who
did not understand subject matter or application of sampling.
The use of qualified personnel and adequate resources is key. Use of experts, when appropriate.
What is RAT STATS?
a. Government hotline for fraud and abuse
b. Government statistical rules (for example sample size)
c. Hospital technology for tracking sampling
,d. Statistical software for hospitals to use - CORRECT ANSWER - b. Government
statistical rules (for example sample size)
In developing a privacy monitoring plan, a privacy professional should initially focus on:
a. Discussion with the business owners
b. Presentation to the BOD
c. Reviewing disciplinary actions
d. Implementing mitigating activities - CORRECT ANSWER - a. Discussion with the
business owners
A person comes to your pharmacy to drop off a prescription for a beneficiary who is a "regular"
customer. The prescription is for a controlled substance with a quantity of 160. This beneficiary
normally receives a quantity of 60, not 160. You review the prescription and have concerns
about possible forgery. What is your next step?
A. Fill the prescription for 160
B. Fill the prescription for 60
C. Call the prescriber to verify quantity
D. Call the sponsor's compliance department
E. Call law enforcement - CORRECT ANSWER - C. Call the prescriber to verify quantity
Call the prescriber to verify. If the subscriber verifies that the quantity should be 60 and not 160
your next step should be to immediately call the sponsor's compliance hotline. The sponsor will
provide next steps.
You used the OIG sampling program RAT-STATS to select a statistical sample. Some of the
files you pulled are messy and would take a long time to review. You saw some other files that
looked well organized. As long as you replace one of the "messy" files one-to-one with a "neat"
one that you find, to keep the sample size the same, how many of the files can you replace?
a. 10 files, regardless of sample size
b. 10% of the sample size
c. Unlimited number of files
, d. None of the above - CORRECT ANSWER - d. None of the above
Sampling size has two types of categories. Name them - CORRECT ANSWER -
Statistical (precision, large areas) and non-statistical (specific to a department unit, person, etc.)
Which of the following statements is true regarding Attorney-Client Privilege?
a. It can be applied to employees, former employees, consultants and public healthcare providers.
b. It applies to documents that were created prior to an investigation with an attorney.
c. It protects disclosures by a client to an attorney as well as the attorney's advice to the client.
d. It applies to the underlying facts of the communications. - CORRECT ANSWER - c. It
protects disclosures by a client to an attorney as well as the attorney's advice to the client.
Explanation: Privilege is a two way street. Both attorney and client communications are
protected.
You are in charge of payment of claims submitted from providers. You notice a certain
diagnostic provider ("Doe Diagnostics") has requested a substantial payment for a large number
of members. Many of these claims are for a certain procedure. You review the same type of
procedure for other diagnostic providers and realize that Doe Diagnostics' claims far exceed any
other provider that you reviewed. What do you do?
A. Call Doe Diagnostics and request additional information for the claims
B. Consult with your immediate supervisor or Compliance Department for next steps
C. Reject the claims
D. Pay the claims - CORRECT ANSWER - B. Consult with your immediate supervisor for
next steps or contact the compliance department (via compliance hotline, Special Investigations
Unit [SIU], or other mechanism)
You do not want to contact the provider. This may jeopardize an investigation. Nor do you want
to pay or reject the claims until further discussions with your supervisor or the compliance
department have occurred, including whether additional documentation is necessary.
ACTUAL Exam Questions and CORRECT
Answers
A healthcare provider must repay to Medicare money paid for a specific type of billed claim.
What type of audit is the MOST likely one used to identify the amount of repayment? -
CORRECT ANSWER - Full statistical audit
A Physician practice are having a hard time determining which claims have been paid in full, and
which claims have not been paid at all. What test would be practical for the group to perform to
validate the claims that have been paid or not paid.
A. Statistical Sampling
B. Rat-Stats
C. Snap Shots
D. Random Sampling - CORRECT ANSWER - A. Statistical Sampling
Regarding statistical sampling, what is an example of failed efforts to use statistical analysis?
a. Users who did not understand subject matter or application of sampling.
b. A well-rounded data sample
c. Knowledgeable staff who are involved in the process
d. Investigations done of improper billing practices - CORRECT ANSWER - a. Users who
did not understand subject matter or application of sampling.
The use of qualified personnel and adequate resources is key. Use of experts, when appropriate.
What is RAT STATS?
a. Government hotline for fraud and abuse
b. Government statistical rules (for example sample size)
c. Hospital technology for tracking sampling
,d. Statistical software for hospitals to use - CORRECT ANSWER - b. Government
statistical rules (for example sample size)
In developing a privacy monitoring plan, a privacy professional should initially focus on:
a. Discussion with the business owners
b. Presentation to the BOD
c. Reviewing disciplinary actions
d. Implementing mitigating activities - CORRECT ANSWER - a. Discussion with the
business owners
A person comes to your pharmacy to drop off a prescription for a beneficiary who is a "regular"
customer. The prescription is for a controlled substance with a quantity of 160. This beneficiary
normally receives a quantity of 60, not 160. You review the prescription and have concerns
about possible forgery. What is your next step?
A. Fill the prescription for 160
B. Fill the prescription for 60
C. Call the prescriber to verify quantity
D. Call the sponsor's compliance department
E. Call law enforcement - CORRECT ANSWER - C. Call the prescriber to verify quantity
Call the prescriber to verify. If the subscriber verifies that the quantity should be 60 and not 160
your next step should be to immediately call the sponsor's compliance hotline. The sponsor will
provide next steps.
You used the OIG sampling program RAT-STATS to select a statistical sample. Some of the
files you pulled are messy and would take a long time to review. You saw some other files that
looked well organized. As long as you replace one of the "messy" files one-to-one with a "neat"
one that you find, to keep the sample size the same, how many of the files can you replace?
a. 10 files, regardless of sample size
b. 10% of the sample size
c. Unlimited number of files
, d. None of the above - CORRECT ANSWER - d. None of the above
Sampling size has two types of categories. Name them - CORRECT ANSWER -
Statistical (precision, large areas) and non-statistical (specific to a department unit, person, etc.)
Which of the following statements is true regarding Attorney-Client Privilege?
a. It can be applied to employees, former employees, consultants and public healthcare providers.
b. It applies to documents that were created prior to an investigation with an attorney.
c. It protects disclosures by a client to an attorney as well as the attorney's advice to the client.
d. It applies to the underlying facts of the communications. - CORRECT ANSWER - c. It
protects disclosures by a client to an attorney as well as the attorney's advice to the client.
Explanation: Privilege is a two way street. Both attorney and client communications are
protected.
You are in charge of payment of claims submitted from providers. You notice a certain
diagnostic provider ("Doe Diagnostics") has requested a substantial payment for a large number
of members. Many of these claims are for a certain procedure. You review the same type of
procedure for other diagnostic providers and realize that Doe Diagnostics' claims far exceed any
other provider that you reviewed. What do you do?
A. Call Doe Diagnostics and request additional information for the claims
B. Consult with your immediate supervisor or Compliance Department for next steps
C. Reject the claims
D. Pay the claims - CORRECT ANSWER - B. Consult with your immediate supervisor for
next steps or contact the compliance department (via compliance hotline, Special Investigations
Unit [SIU], or other mechanism)
You do not want to contact the provider. This may jeopardize an investigation. Nor do you want
to pay or reject the claims until further discussions with your supervisor or the compliance
department have occurred, including whether additional documentation is necessary.
