Which statement is TRUE regarding an audit performed
D. National CMS policies and local MAC policies should be
on charts for Medicare beneficiaries?
utilized when performing Medicare audits.
A. National CMS policies override local carrier policy, so
Rationale: In addition to CMS policies, it is important to
all Medicare audits should only go by National CMS poli-
verify information from the Medicare Administrative Con-
cies.
tractor (MAC) that supports the location where the services
B. It is necessary to review CMS National policies, local
being audited were provided. In some instances, the MAC
MAC policies, and multiple commercial insurance policies
will have very specific information as to what constitutes
when performing Medicare audits.
a detailed history or exam, versus an expanded problem
C. Commercial insurance policies and CMS National poli-
focused. It is helpful to consult the MAC's website to de-
cies should be utilized when performing Medicare au-
termine if it has published its own set of guidelines in re-
dits.
lation to electronic medical records, and what acceptable
D. National CMS policies and local MAC policies should be
standards are used for an electronic record.
utilized when performing Medicare audits.
Which statement is FALSE regarding audits?
B. Audits must be performed internally before external
A. Audits can be focused on one service within a practice. auditors are retained.
B. Audits must be performed internally before external
Rationale: Audits may be performed internally or external-
auditors are retained.
ly. There is no requirement for an audit to be performed
C. Audits may be performed internally or externally.
internally before external auditors are retained.
D. Audits can identify risk areas within a practice.
What is an advantage of a peer review audit?
C. To allow providers to learn from each other and improve
A. To focus on one type of service to determine compli- their practice.
ance
Rationale: The purpose of a peer review audit is to ensure
B. To compare coding to other practices for upcoding
the accuracy and appropriateness of clinical decision mak-
trends
ing and coding within a practice. It provides an opportu-
C. To identify which physician is undercoding the most in
nity for providers to learn from each other and improve
the practice
their practice. This, in turn, can help improve patient care
D. To allow providers to learn from each other and improve
and ensure accurate billing.
their practice
, What is numerical sampling?
C. Sampling based on all possible services within a chosen
A. Sample based on unique services that were defined in time frame.
the objective and scope, and is used in focused audits.
Rationale: One of the statistical methods of sampling is
B. Sampling based on high frequency items, or those
known as numerical sampling. In this methodology, the
items that are considered to be proportionally significant.
sample size is based on all possible services within the
C. Sampling based on all possible services within a chosen
chosen time frame. This type of sample lends itself well to
time frame.
a random final selection.
D. Sampling based on provider recommendations.
D. Utilization reports
What tool might be helpful in defining which services to
audit for a focused review? Rationale: Utilization review and data mining provide in-
sight into billing patterns and can help uncover areas of
A. RAT-STATS
risk. Utilization review is a technique that provides data
B. Numerical sampling
about how frequently certain services are billed. A utiliza-
C. Random sampling
tion pattern can be found from looking at the utilization
D. Utilization reports
review to evaluate coding patterns.
C. A technique that provides data about how frequently
What is a utilization review? certain services are billed.
A. A review performed by the OIG to determine accuracy Rationale: Utilization review is a technique that provides
of payments. data about how frequently certain services are billed. A
B. A technique that provides data about the cost of services utilization pattern can be found from looking at the utiliza-
provided to Medicare beneficiaries. tion review to evaluate coding patterns. Data mining is a
C. A technique that provides data about how frequently method that many payers use to compare billing frequen-
certain services are billed. cies of one provider against other, similar providers of the
D. A review performed by CMS to determine which region same specialty. These two methodologies work together
pays out a higher amount per Medicare beneficiary. to show if a provider falls out of a normal pattern when
compared with other, similar providers.
Which type of audit often realizes more objectivity than C. External audit
with an employed auditor?
D. National CMS policies and local MAC policies should be
on charts for Medicare beneficiaries?
utilized when performing Medicare audits.
A. National CMS policies override local carrier policy, so
Rationale: In addition to CMS policies, it is important to
all Medicare audits should only go by National CMS poli-
verify information from the Medicare Administrative Con-
cies.
tractor (MAC) that supports the location where the services
B. It is necessary to review CMS National policies, local
being audited were provided. In some instances, the MAC
MAC policies, and multiple commercial insurance policies
will have very specific information as to what constitutes
when performing Medicare audits.
a detailed history or exam, versus an expanded problem
C. Commercial insurance policies and CMS National poli-
focused. It is helpful to consult the MAC's website to de-
cies should be utilized when performing Medicare au-
termine if it has published its own set of guidelines in re-
dits.
lation to electronic medical records, and what acceptable
D. National CMS policies and local MAC policies should be
standards are used for an electronic record.
utilized when performing Medicare audits.
Which statement is FALSE regarding audits?
B. Audits must be performed internally before external
A. Audits can be focused on one service within a practice. auditors are retained.
B. Audits must be performed internally before external
Rationale: Audits may be performed internally or external-
auditors are retained.
ly. There is no requirement for an audit to be performed
C. Audits may be performed internally or externally.
internally before external auditors are retained.
D. Audits can identify risk areas within a practice.
What is an advantage of a peer review audit?
C. To allow providers to learn from each other and improve
A. To focus on one type of service to determine compli- their practice.
ance
Rationale: The purpose of a peer review audit is to ensure
B. To compare coding to other practices for upcoding
the accuracy and appropriateness of clinical decision mak-
trends
ing and coding within a practice. It provides an opportu-
C. To identify which physician is undercoding the most in
nity for providers to learn from each other and improve
the practice
their practice. This, in turn, can help improve patient care
D. To allow providers to learn from each other and improve
and ensure accurate billing.
their practice
, What is numerical sampling?
C. Sampling based on all possible services within a chosen
A. Sample based on unique services that were defined in time frame.
the objective and scope, and is used in focused audits.
Rationale: One of the statistical methods of sampling is
B. Sampling based on high frequency items, or those
known as numerical sampling. In this methodology, the
items that are considered to be proportionally significant.
sample size is based on all possible services within the
C. Sampling based on all possible services within a chosen
chosen time frame. This type of sample lends itself well to
time frame.
a random final selection.
D. Sampling based on provider recommendations.
D. Utilization reports
What tool might be helpful in defining which services to
audit for a focused review? Rationale: Utilization review and data mining provide in-
sight into billing patterns and can help uncover areas of
A. RAT-STATS
risk. Utilization review is a technique that provides data
B. Numerical sampling
about how frequently certain services are billed. A utiliza-
C. Random sampling
tion pattern can be found from looking at the utilization
D. Utilization reports
review to evaluate coding patterns.
C. A technique that provides data about how frequently
What is a utilization review? certain services are billed.
A. A review performed by the OIG to determine accuracy Rationale: Utilization review is a technique that provides
of payments. data about how frequently certain services are billed. A
B. A technique that provides data about the cost of services utilization pattern can be found from looking at the utiliza-
provided to Medicare beneficiaries. tion review to evaluate coding patterns. Data mining is a
C. A technique that provides data about how frequently method that many payers use to compare billing frequen-
certain services are billed. cies of one provider against other, similar providers of the
D. A review performed by CMS to determine which region same specialty. These two methodologies work together
pays out a higher amount per Medicare beneficiary. to show if a provider falls out of a normal pattern when
compared with other, similar providers.
Which type of audit often realizes more objectivity than C. External audit
with an employed auditor?
