Quality Assurance and Compliance Auditing
Building a defensible audit program
Compliance auditing verifies that billing, coding, and documentation meet legal and payer requirements. A candidate must understand the elements of an effective compliance program: written policies, a compliance officer, training, monitoring and auditing, a hotline, enforcement, and corrective action. Know the seven elements of the federal sentencing guidelines for compliance programs, as adapted for health care.
Concepts to master
Understand sampling methodologies-random, stratified, and targeted-and how extrapolation works in audits. Know the difference between internal audits and external reviews by RACs, MACs, and payers. Familiarize yourself with root cause analysis, corrective action plans, and the concept of a baseline audit followed by monitoring. Understand how error rates are calculated and reported.
Traps in questions
Distractors often confuse an internal audit with an official government audit, or assume extrapolation requires a 100% review. Another trap: treating a corrective action plan as optional after a finding. Questions may also test whether a compliance officer can also serve as the auditor without independence concerns.
Rule of thumb
An audit finding without a corrective action plan is incomplete. Worked example: a baseline audit of 50 claims finds 5 coding errors, an error rate of 10%. The organization should document the root cause, implement education, and re-audit a sample to confirm improvement. Extrapolation of that rate to the population may be appropriate if the sample was statistically valid.