Chapter 37 — Quiz

26 questions: multiple choice and short answer. The answer key is in the collapsed block at the bottom. All dollar figures, universes, samples, and confidence levels are this book's constructed teaching figures; verify every real-world program parameter at CMS and the OIG.

1. The best one-sentence description of an audit, as this chapter uses the word, is:

• A. A search for fraud
• B. A structured reading of completed work against a written standard, producing a scored result
• C. A payer's decision to deny a claim
• D. A quality-improvement meeting

2. An internal audit that has found no errors for six consecutive quarters most likely indicates:

• A. Excellence
• B. A sample too small, a standard too vague, or an auditor who is not independent
• C. That no further auditing is required
• D. That the practice should reduce its compliance budget

3. Which of the seven elements of an effective compliance program (Chapter 5 §5.6) does an internal audit directly satisfy?

• A. Written policies and standards of conduct
• B. A designated compliance officer
• C. Internal monitoring and auditing
• D. Well-publicized disciplinary guidelines

4. Short answer: define the audit universe, and state the one thing every universe statement must end with.

5. A probe audit is best described as:

• A. A statistically valid sample from which an error rate may be projected
• B. A small, limited first review whose purpose is to decide whether a larger review is needed
• C. A review performed only by external contractors
• D. A review of every claim in a period

6. A claim with a March date of service is scored by a contractor against a policy revised in October of the same year. This is:

• A. Correct — contractors apply current policy
• B. Correct only for Medicare
• C. Incorrect — a claim is scored against the rules in force on its date of service
• D. Incorrect only if the provider objects within 30 days

7. Short answer: name the three "legs" of an audit universe described in §37.2, and state which one finds an error that exists only in aggregate.

8. A chart audit of ten records touched by an auto-appending modifier macro will most likely show:

• A. Random variation across the ten
• B. The modifier on all ten, an internally consistent sample, and no signal at all
• C. The macro's configuration screen
• D. A financial variance in both directions

9. A reviewed chart has four lines; one carries an unsupported modifier. Code-level accuracy and chart-level accuracy are, respectively:

• A. 75% and 75%
• B. 75% and 0%
• C. 100% and 75%
• D. 0% and 75%

10. Short answer: which accuracy measure is closest to how an external reviewer will score you, and why does that matter when an extrapolation is applied?

11. The scoring category "supported, but the record is fragile":

• A. Removes the code
• B. Changes the financial variance
• C. Changes nothing on the claim and predicts next year's errors
• D. Is only used in facility audits

12. Prepayment review differs from postpayment review in that:

• A. It creates an overpayment to be recovered
• B. Claims suspend before adjudication and are paid, reduced, or denied on the documentation
• C. It applies only to hospitals
• D. It carries no response deadline

13. An additional documentation request (ADR) that goes unanswered results in:

• A. A neutral outcome; the claim simply pends
• B. A denial for insufficient documentation, scored as an error
• C. Automatic escalation to an appeal
• D. Removal from prepayment review

14. Short answer: name the three things a provider must do to come off prepayment review, and state why winning individual appeals is not one of them.

15. Targeted Probe and Educate (TPE) is:

• A. A separate federal contractor
• B. A MAC program: a small provider-specific probe sample followed by one-on-one education, repeated for a defined number of rounds
• C. A postpayment recovery program paid on contingency
• D. The national improper payment measurement program

16. The Recovery Audit Contractor program is distinctive because it:

• A. Reviews only prepayment
• B. Is paid a contingency fee on what it finds, and is required to identify underpayments as well as overpayments
• C. Cannot request medical records
• D. Reports only to the OIG

17. The Supplemental Medical Review Contractor (SMRC) differs from the RAC in that the SMRC:

• A. Is paid on contingency
• B. Reviews only inpatient claims
• C. Does not recover money; it refers its findings to the MAC
• D. Only performs automated review

18. Comprehensive Error Rate Testing (CERT) produces:

• A. A fraud rate
• B. A national improper payment rate from a random sample of Medicare fee-for-service claims
• C. A provider-specific error rate used to place providers on review
• D. A list of approved audit issues

19. A letter from a Unified Program Integrity Contractor is distinguished by:

• A. Its focus on benefit integrity — fraud, waste, and abuse — rather than billing error
• B. Its short response deadline
• C. Its use of automated review only
• D. Its contingency-fee funding

20. Short answer: what governs a commercial payer's authority to request records, look back, recoup, and extrapolate — and what does not govern it?

21. A payer defines a universe of 380 claims, samples 42, and finds a mean overpayment of \$612.40. The point estimate of the total overpayment is:

• A. \$25,720.80
• B. \$204,489.40
• C. \$232,712.00
• D. \$612.40

22. In the same review, the contractor demands the lower limit of a two-sided 90 percent confidence interval rather than the point estimate. The reason is:

• A. To reduce the paperwork
• B. To resolve the uncertainty introduced by sampling in the provider's favor
• C. Because the point estimate is not computable
• D. Because the provider requested it

23. Holding the mean overpayment constant, a smaller sample standard deviation produces:

• A. A smaller demand, because the errors are smaller
• B. A larger demand, because the confidence interval narrows and the lower bound rises
• C. No change to the demand
• D. An automatic invalidation of the sample

24. Short answer: state, in two sentences, why the demand on Account 31-2245 was \$25,720.80 rather than a six-figure number — and what would have had to be different for it to be six figures.

25. For the sixty-day overpayment rule, an overpayment is "identified" when:

• A. A payer sends a demand letter
• B. Someone suspects an error
• C. The person has determined — or should have, exercising the required diligence — that an overpayment was received, and has quantified it
• D. Counsel has been retained

26. Short answer: name the durability ladder's four rungs in order, state which rung most corrective action plans stop at, and give the one sentence that explains why that rung decays.