CHA Healthcare Auditor flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

False Claims Act

Federal law imposing liability for knowingly submitting false claims to government payers; penalties per claim plus treble damages; qui tam provisions allow whistleblowers to sue.

Anti-Kickback Statute

Prohibits offering, paying, soliciting, or receiving remuneration to induce referrals of federally reimbursed items or services; safe harbors provide protection.

Stark Law

Prohibits physician self-referral for designated health services when a financial relationship exists, unless an exception applies; strict liability standard.

HIPAA Privacy Rule

Regulates use and disclosure of protected health information; grants patient rights and requires minimum necessary disclosures and safeguards.

Seven Elements of Compliance

OIG framework: written policies, compliance officer/committee, training, communication lines, auditing/monitoring, discipline, and corrective action.

EMTALA

Requires hospitals to provide screening and stabilization for emergency conditions regardless of ability to pay; violations can lead to exclusion from Medicare.

Independence

Internal auditors must be free from conditions that threaten objectivity; no management responsibilities; report functionally to the board or audit committee.

Due Professional Care

Internal auditors apply the knowledge, skills, and experience expected of a reasonably prudent auditor; does not imply infallibility.

Quality Assurance Program

QAIP includes ongoing and periodic internal assessments and an external assessment at least every five years to evaluate audit activity effectiveness.

Professional Skepticism

An attitude of questioning contradictions, verifying assertions, and following up on inconsistencies during audit work.

Materiality

Threshold used to determine significance of misstatements; considers quantitative (e.g., percent of revenue) and qualitative factors (fraud, regulatory).

Audit Universe

Inventory of all auditable entities or processes; used to prioritize audits based on risk, materiality, and time since last audit.

Residual Risk

Risk remaining after considering the effectiveness of existing controls; used to prioritize audit coverage.

Walkthrough

Tracing a transaction from start to finish to understand process flow and identify key controls and gaps.

Attribute Sampling

Statistical sampling used to estimate the deviation rate of a control in a population; results projected to the population.

Sampling Risk

Risk that the conclusion based on a sample differs from the conclusion if the entire population were tested.

Analytical Procedures

Evaluations of financial or operational information by comparing to expectations (trends, ratios, benchmarks) and investigating significant variances.

Sufficiency of Evidence

The quantity of audit evidence; appropriateness relates to relevance and reliability. More evidence is needed for higher-risk areas.

Charge Capture

Process of recording services and supplies provided to patients for billing; controls include charge master maintenance and reconciliation.

NCCI Edits

National Correct Coding Initiative edits prevent improper payment for services that should not be billed together; include bundling and modifier rules.

Upcoding

Assigning a higher-level or more complex code than documented to increase reimbursement; a common fraud and abuse risk.

Medical Necessity

Services must be reasonable and necessary for diagnosis or treatment; supported by documentation and coverage determinations (LCD/NCD).

CDI Program

Clinical documentation integrity program improves documentation accuracy through physician queries; queries must be non-leading and compliant.

HEDIS

Healthcare Effectiveness Data and Information Set: quality measures used to assess performance; audits verify numerator/denominator accuracy.

Hospital-Acquired Condition

A condition acquired during hospitalization that was not present on admission; quality audits target prevention and reporting.

Physician Query

Communication to clarify ambiguous or incomplete documentation; must be non-leading and include clinical indicators.

Minimum Necessary

HIPAA requirement to limit use and disclosure of PHI to the minimum amount needed to accomplish the intended purpose.

Breach Notification

Requires notifying affected individuals without unreasonable delay and no later than 60 days after discovery; HHS notification if >500 individuals.

Business Associate Agreement

Contract required when a vendor handles PHI; must include required HIPAA provisions and safeguards.

Audit Finding Elements

Criteria, condition, cause, and effect; recommendations and management response are also included in the report.

Follow-Up Audit

Verifies that management has implemented corrective actions within committed timelines; tracks open issues.

Waste and Abuse

Waste is misuse of resources without intent; abuse is practices inconsistent with sound business or medical practices, not necessarily intentional fraud.