Medical Auditing Practice Exam

A post-payment audit is typically triggered by a high volume of denied claims from a specific payer. This situation raises red flags that may indicate potential issues with billing practices, documentation, coding accuracy, or compliance with payer-specific guidelines. When a provider experiences a substantial number of denied claims, it suggests a possible systemic problem that warrants further investigation to ensure that correct practices are being adhered to. In contrast, a provider's request for additional funding does not inherently point to necessary audits—it may instead be related to administrative operations or financial management. Changes in government regulations could influence billing and coding practices, but they do not automatically initiate a post-payment audit; instead, they generally require adjustments in practice to maintain compliance. Routine procedural updates, while important for keeping practice operations current, are not triggers for audits as they don’t indicate discrepancies or issues that need review. Thus, the scenario of having a high volume of denied claims specifically highlights the need to investigate and possibly rectify issues within the billing process, making it the correct rationale for initiating a post-payment audit.