auditor medical claims Interview Questions and Answers

1. What is the role of a medical claims auditor?

   • Answer: A medical claims auditor reviews medical claims for accuracy, compliance with regulations, and prevention of fraud and abuse. They ensure proper coding, billing practices, and that services provided were medically necessary.

2. Explain the difference between pre-payment and post-payment audits.

   • Answer: Pre-payment audits review claims *before* payment is issued, identifying potential issues early. Post-payment audits review claims *after* payment, focusing on identifying overpayments or fraudulent activities.

3. What are some common types of medical claims fraud?

   • Answer: Common types include upcoding (billing for a more expensive service than provided), unbundling (billing for separate components of a procedure that should be billed as a single unit), phantom billing (billing for services not rendered), and duplicate billing.

4. How familiar are you with HIPAA regulations?

   • Answer: I am very familiar with HIPAA regulations, including the Privacy Rule, Security Rule, and Breach Notification Rule. I understand the importance of protecting patient health information (PHI) and adhering to all relevant guidelines.

5. What is your experience with different coding systems (e.g., ICD-10, CPT, HCPCS)?

   • Answer: I have extensive experience with ICD-10, CPT, and HCPCS coding systems. I understand the nuances of each system and how to accurately apply them to various medical procedures and diagnoses.

6. Describe your experience using claims auditing software.

   • Answer: I have experience using [Specific software names, e.g., FAIMS, Optum360]. I am proficient in using the software to analyze claims data, identify trends, and generate reports.

7. How do you handle discrepancies or inconsistencies found during an audit?

   • Answer: I carefully document all discrepancies, contact the provider to clarify the issues, and obtain supporting documentation. I follow established protocols for resolving identified problems and reporting findings.

8. What is medical necessity and how do you determine it during an audit?

   • Answer: Medical necessity refers to whether a service or procedure is appropriate and necessary for the patient's diagnosis and treatment. I determine this by reviewing medical records, comparing the treatment to established guidelines, and ensuring the services align with the patient's condition.

9. How do you prioritize claims for auditing?

   • Answer: Prioritization depends on factors like risk assessment, payment amount, provider history, and regulatory requirements. High-risk providers or claims with high dollar amounts would generally be prioritized.

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