After identifying a sample, what is the auditor responsible for determining?

In the context of auditing medical claims, after identifying a sample, the auditor's primary responsibility is to determine whether the sampled claims were reported appropriately. This means reviewing each claim in the sample to ensure that all documentation is accurate, complete, and in line with the established coding guidelines and regulations. This process is crucial because it verifies that the claims reflect the services provided and that they comply with applicable billing and regulatory standards.

Determining whether claims were accurately reported is essential for identifying potential overbilling or underbilling issues, not only to maintain compliance but also to protect the provider from potential audits or penalties. This thorough review enables the auditor to form conclusions about the overall adherence to coding protocols and compliance practices within the organization.

The financial impact of compliance, while important for overall organizational health, typically falls under broader financial assessments rather than being the immediate responsibility of the auditor regarding individual sampled claims. Similarly, knowing the total number of claims or assessing coding adequacy are significant, but they do not directly address the auditor's immediate task of analyzing the specific claims within the sample for their correctness and compliance with regulations.