Monitoring, Auditing, and Internal Investigations
Monitoring vs. Auditing
Monitoring is ongoing, routine oversight (e.g., monthly pre-bill reviews, manager spot checks). Auditing is periodic, independent, systematic review against defined criteria (e.g., an annual coding audit of a sample of claims). Questions often ask you to classify an activity; the tell is frequency and independence.
Designing Reviews
Good reviews define scope, criteria, sampling method, and reporting. Findings should be tracked to closure with owners and deadlines. A trap is a review with no defined criteria or no follow-up - it produces observations, not assurance.
Internal Investigations
Investigations must be prompt, impartial, confidential to the extent possible, and documented. Steps: intake and triage, plan, gather evidence, interview, analyze, conclude, and remediate. Preserve documents and avoid conflicts of interest (the investigator should not be the subject's ally or the accused). Avoid retaliation against reporters. A frequent trap is jumping to discipline before gathering facts, or letting the manager who is the subject run the investigation.
Worked Example
An employee reports suspected upcoding. The best first step is to document the report, assess urgency, and assign an impartial investigator - not to confront the suspected coder or promise confidentiality you cannot keep. Rule of thumb: investigate facts first, decide consequences later, and always protect the reporter.
Common Traps
- Confusing monitoring (ongoing) with auditing (periodic, independent).
- Skipping documentation or closure of findings.
- Overpromising absolute confidentiality.
- Allowing conflicts of interest in investigations.
- Ignoring anti-retaliation obligations.