Why Auditing Methodology Matters
Auditing is one of the seven core elements of an effective compliance program, and the specific methodology used affects both the reliability of findings and the defensibility of the program in front of regulators. RHIA candidates should understand the major approaches to compliance auditing in healthcare settings.
Types of Compliance Audits
- Baseline audits establish a starting point for measuring compliance risk across an organization or department
- Focused audits target a specific risk area identified through prior findings, industry alerts, or OIG work plan priorities
- Random sample audits select claims or records without regard to known risk, providing a broader view of general compliance
- Risk-based audits concentrate resources on areas identified as high-risk through a formal risk assessment
Statistical Sampling Approaches
Coding and billing audits commonly use statistical sampling methods, including simple random sampling and stratified random sampling, to draw conclusions about a larger population of claims. RHIA candidates should understand why a statistically valid sample is important when an audit's findings will be extrapolated to estimate an overpayment across an entire claims population, as required in many OIG and CMS audit contexts.
Internal vs External Audits
Internal audits are conducted by an organization's own compliance or internal audit staff and offer speed and institutional knowledge. External audits, conducted by outside consultants or law firms, offer independence and can be protected under attorney-client privilege when structured appropriately, which is valuable when an audit may uncover evidence relevant to potential legal exposure.
The Audit Cycle
- Planning, including defining the scope, sample size, and audit criteria
- Fieldwork, involving record review, data collection, and interviews as needed
- Reporting, summarizing findings, error rates, and root causes
- Corrective action, addressing identified deficiencies through training, process change, or repayment
- Follow-up, verifying that corrective actions were implemented and effective
Common Findings in HIM-Related Audits
Frequent audit findings include insufficient documentation to support billed codes, missing physician signatures or authentication, mismatched diagnosis and procedure codes, and untimely completion of medical records affecting billing timeliness.
Exam Strategy
Expect the exam to test whether you can identify the appropriate audit type for a described risk, distinguish sampling methodologies, and recognize the stages of the audit cycle within a scenario.
Key Takeaway
Effective compliance auditing combines the right audit type, valid sampling methodology, and a disciplined follow-through process, all of which are testable concepts for the RHIA exam.