...Evaluating Compliance Strategies HCR/220 Compliant billing involves certain steps in order to properly bill a patient and receive any monies owed for those services performed. First step is for the doctor to fill out and sign any and all forms at the end of a patient’s visit. The next step is to post the transactions made along with the proper medical codes from a patient’s appointment into the practice management program which leads to the claims being filed. Payers then need to make sure that the services performed along with the diagnosis must show that it was medically necessary services. The billers also need to know the proper rules and guidelines put forth by a patient’s insurance company. Because medical insurance companies constantly change their policies, the insurance specialist rely on the payer’s website or may regular communicate with a representative of the payer. The correct coding initiative controls improper coding that would result in improper payments for Medicare claims. The CCI also monitors billing of any services that Medicare believes cannot be performed together. The CCI also requires doctors to tell about the most extensive service that was performed and not the revealing of both the extensive and limited services. Finally the CCI also tests for unbundling. Many mistakes can be made while billing/coding a patient. Some of those mistakes are: billing invalid/outdated codes, coding without the correct forms, truncated coding; using codes that...
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...Evaluating Compliance Strategies Patricia Estrada HCR/220 November 2012 Deborah Ryan Medical billing and compliance strategies are used to bill for medical procedures and treatments. The compliance strategies are in place to prevent incorrect billing, but mistakes are still made. Answers to the importance of correctly linking procedures and diagnoses, the implications of incorrect medical coding, and how medical coding, physicians and payer fees are related to the compliance process will be discussed. It is very important that procedures and diagnosis are correctly linked together. There are certain steps to follow that help to correctly link the procedure to the diagnoses. By following the correct procedures to apply the correct codes that link procedure with diagnosis, insurance companies can be correctly billed for reimbursements. Correctly connected claims can be analyzed and to make sure charges are for medically necessary services provided to the patient. Correct claims help reduce the chance of an investigation of the practice of fraud and the risk of liability in an investigation does occur. (Valerius, J., Bayes, N., Newby, C., & Seggern, J. , 2008). If the procedures are not linked correctly to the diagnoses, then they will not be covered by the insurance company and therefor will not be paid. The major implication of incorrect medical coding would be fraud. Even though incorrect work may simply be an error, it may also represent a deliberate attempt...
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...Evaluation Compliance Strategies Medical Billing and coding compliance is very important to the billing world. Billing management starts at the first patient contact and ends only when the account has been paid in full. . In between, there are a series of important steps, each of which is critical for accurate billing and proper reimbursement. In this essay we are going to discuss the importance of the linkage code, implications of incorrect medical coding, and how physicians and payers fee are related to the billing compliance. We are also going to discuss what steps we can take to meet the compliance standards. When claims are filed correctly they will show the connection between the service being billed and the diagnosis code. The linkage code helps determine which procedure goes with which diagnosis code. If the linkage codes are not correct this will cause the claim to be denied. Linkage codes help the payer to determine the medical necessity for the service provided. Payers will determine the coverage by medical necessity. Services that are considered to be of nonmedical necessity are not covered under an insurance policy. It is important that the billing specialist be aware that different payers will have their own set of medical necessity edits. The implications of incorrect medical coding can cause issues for both the medical provider and the patient. Coding incorrectly can cause denial of claims. Providers would lose their patients trust, causing them to...
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...In the health care field the compliance process is designed to ensure the maximum benefit for health care claims. The compliance process is made up of guidelines set forth by the Health Insurance Portability Accountability Act and by the healthcare staff. These guidelines are setup to protect the physicians, patients, and medical staff. Medical offices can help to reduce errors by making sure that the staff is properly trained and that the office has updated coding and billing software. I think that each office should have a guide that consists of codes which would aid the employees in the billing process. Some offices currently use sheets that are in the front the patients file that contain diagnosis and the codes, which is filled out by the physician. This helps reduce errors in the billing process when the physician completes the code themselves. The Medicare National Correct Coding Initiative is responsible for controlling improper coding and invalid payments for Medicare claims. It is extremely important to correctly link the procedures and diagnoses so that the claim will not be rejected. When claims are rejected due to incorrect linking of the procedures and diagnoses this could result in a loss of money by the physician or the medical facility. When this error occurs claims have to adjusted and then resubmitted, which results in outstanding patient balances due to errors in the medical office. The main implication that occurs form incorrect medical coding...
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...A. Compliance Status The following executive summary focuses not only on the identified gaps in the current process, but also the corrective action plan to support compliance in the noted areas of the Communications Standards as provided by The Joint Commission, (National Patient Safety Goals, 2013). The high risk associated with surgical procedures performed on the wrong site has driven a risk mitigating approach to the processes involved for these procedures. The goal is to prevent harm to patients having a surgical procedure. The following summary is the current compliance status if the Priority Focus Area of Communication for Nightingale Community Hospital. After review of the specific areas identified in the Priority Focus Area, the following have been identified as requiring further attention: time-outs are routinely performed prior to every procedure (UP 01.03.01) and procedure site is marked (UP 01.02.01). Based on the evaluation of the Nightingale Community Hospital National Patient Safety Goals for Communications the current compliance rate related to the Universal Protocol Time-Out processes performed hospital wide indicate a 95% to 100% compliance rate for the year. The graph provided in the Nightingale Community Hospital National Patient Safety Goals Communication assessment provides limited information as these are hospital wide percentages. No unit specific evaluations of performance have been provided in the report. Upon review of the Site Identification and...
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...encourages greater ethical accountability for companies to demonstrate they are abiding by the law and have established programs to improve their ethical decision making. The U.S. Sentencing Commission (the “Commission) has amended the Federal Sentencing Guidelines for Organizations (“FSGO”) whereby an effective compliance and ethics program must “exercise due diligence to prevent, detect, and report criminal conduct and otherwise promote an organizational culture that encourages ethical conduct and a commitment to compliance with all applicable law." The Commission noted there are seven minimum requirements of an effective ethics program, standards and procedures to prevent and detect criminal conduct; Responsibility at all levels of the program, together with adequate program resources and authority for its managers; Due diligence in hiring and assigning personnel to positions with substantial authority; Communicating standards and procedures, including a specific requirement for training at all levels; Monitoring, auditing, and non-retaliatory internal guidance/reporting systems, including periodic evaluation of program effectiveness; Promotion and enforcement of compliance and ethical conduct; and taking reasonable steps to respond appropriately and prevent further misconduct upon detecting a violation. Better business bureau torch award audit process The Better...
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...Evaluation Of A Business Code Of Ethics YourFirstName YourLastName University title Introduction A chief executive officer cannot simply make the decision that is best for her without considering the interests of other employees, stockholders, customers, suppliers, creditors, and so forth. Integrity is the cornerstone of ethical business practices. Failure to build a business on integrity carries costs. For example, deceptive business practices may harm a company's standing in the community, decrease employee productivity, reduce customer loyalty, build resentment among employees, increase the likelihood of further unethical behavior by employees, and cause scrutiny by government agencies. Although the costs of some of these consequences are difficult to quantify, there is no doubt that they can be substantial. Evaluate chosen strategy King and Spalding is a legal firm that was founded in 1885, Atlanta. It has a total of 800 lawyers across the U.S, Europe, Asia and Middle East. Ethics Programs Companies frequently create ethics programs to establish and help maintain an ethical business environment. Some of the most common elements of ethics pro-grams at King & Spalding include written codes of ethics, employee hotlines and ethics call centers, ethics training, processes to register anonymous complaints about wrongdoing, and ethics offices. Ethics programs may include any combination of these elements. However, according to a recent survey, an ethics program...
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...Ethics and Compliance David Livingston, Raul Lopez, Robert Morrison, Tyler Norwood FIN/370 Finance for Business University of Phoenix May 7, 2011 Joe Brennan Ethics and Compliance Even though there are federal rules and regulations governing work place behavior, what if there were no boundaries for ethics and compliance, would Amazon continue to follow the same procedures set by the federal laws to ensure ethical behavior within the work place. How does Amazon differ from other organizations when it comes to ethical behavior? One way is because Amazon adheres to a strict conflict of interest policy regarding customers, employees, and Amazon follows strict policies on record keeping and financial integrity. Team C will depict Amazon’s policy and procedures for ethical and SEC compliance, explain the function of monetary markets in the United States, and assess Amazon’s monetary performance for the previous two years by means of financial ratios. Team C will explain Amazon’s financial health in reference to the debt, return of equity, and daily receivable ratios. As part of their code of business conduct and ethics policies, Amazon established basic guiding principles to help steer their employees to do what is ethically and morally right to reassure their investors that they are doing what is right for the investors and the public. Of course Amazon must be in compliance with the governing (a) laws, (b) rules and (c) regulations set forth by local and federal governments...
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...CODE OF ETHICS Compliance is the responsibility of all the Company’s directors, officers, managers, and employees.(Capital One,2011). One is responsible for learning the details of the policies, procedures, laws and regulations applicable to one's job and for seeking guidance when needed. It is important to avoid misconduct that violates the law, this Code, or Company policies, but also the appearance of impropriety. The point, which a subject is not explicitly explained in this Code, does not relieve an employee of their responsibility to maintain the highest ethical standards under all circumstances. If one has any concern about whether their actions or inactions could violate a law, it should be discussed with their manager. While no Code of Ethics can or should replace thoughtful behavior or common sense, it can help cultivate a culture that values and rewards honesty, integrity, and accountability. (Avon, n.d.). The principles detailed in the Code will guide in “doing the right thing” and in preserving the Company’s reputation for acting with integrity at all times. TRADE REGULATION Most states have enacted trade regulation laws to ensure fair competition. These laws prohibit price-fixing and other "anti-competitive agreements, deceptive acts, and unfair competitive methods." (Pension Consulting, n.d.). Some forms of joint activities are legally permissible, but others are not. Under no circumstances, should you illegally or improperly...
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...Compliance Interview and Report Assignment BA 3301 Legal Environment of Business Associate Professor Lee Usnick, JD I. ASSIGNMENT OVERVIEW Virtually all business activities conducted in the United States are highly regulated, not only by governmental entities, but by professional entities as well. Compliance with all federal, state, and local laws and regulations is a prerequisite to the long term health and survival of a business. Also important is compliance with standards issued by the professional and accrediting bodies responsible for licensing and certification. Certain industries are more regulated than others. For example, health care, financial services, and public utilities are all highly regulated with extensive licensing and operational standards. When a business fails to comply with all applicable regulations and standards, the business and the individuals who manage it can face a variety of sanctions, from loss of license and program certification, to civil and criminal sanctions including monetary penalties and prison. In this assignment, you will learn how a person working in your selected industry meets the challenges of current compliance requirements. It is not necessary to address all aspects of compliance in this industry or selected company. Rather, you should educate yourself in broad terms about the kinds of governmental and industry standards covering your interviewee's business, then select a few key aspects to explore in depth with your...
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...Effectiveness of Compliance Programs Pradeep Parakh, Mumbai, India Why to have a Compliance Plan • Heightened scrutiny by regulators • Avoid problems before they occur • Improved effectiveness of organization The Importance of Compliance • Compliance provides stability in revenue • Compliance uncovers inadvertent errors which can be corrected before they create huge problems for the entity • Compliance allows continued service to consumers because paybacks and penalties can impact the delivery of future services • Compliance leads to a better relationship with regulators and those who have dealings with the entity Compliance Programs Must Have Substance • As evident by recent legislation, the focus of regulators is shifting from a focus on the presence of a compliance program to evidence that demonstrates the effectiveness of the compliance program • Regulators asks question such as – “Can you prove that your compliance program works?” Elements of Effective Compliance Plan • Written policies and procedures • Compliance Officer • Training and education . . . including . . .governing body members • Communication lines to the Compliance Officer • Disciplinary policies • Internal audits and, as appropriate, external audits • Response and investigation Types of Compliance Programs People Measure • • • • • • • • Security compliance Regulatory compliance Listing compliance Environmental compliance Safety compliance Quality control compliance Privacy compliance Tax compliance Counts...
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...& Compliance Officer In Accenture’s ethics and compliance program, the company uses six “core values” of stewardship, best people, client value creation, one global network, respect for the individual and integrity. Douglas Scrivner, General Counsel at Accenture, says that ethics and compliance can’t be effective if they’re only seen as “bolt-ons,” or something that is only done at the end of the day after the “regular work” is complete. “We aim to put ethics and compliance into the way our people work and lead. We seek to leverage existing processes, procedures, structures and functions to ensure the outcomes we are expecting and alignment with the goals of the organization,” says Scrivner. To better understand how the company’s ethics and compliance program is being received by employees, Accenture uses employee surveys, risk assessments and results of corporate investigations. Scrivner notes that in a recent survey, over 90 percent of employees feel that Accenture is highly ethical and that the company’s commitment to integrity has been communicated to the whole company. “Those are excellent scores for a company of more than 181,000 people,” Scrivner says. “We haven’t arrived at the end of our journey (and never will), but I am confident that we continue to move in the right direction and continually reinforce our commitment and our expectations in this area.” Caterpillar Ed Scott, Chief Ethics & Compliance Officer Ed Scott, Chief Ethics and Compliance Officer...
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...BA 3301 Legal Environment of Business Compliance Interview and Report Assignment Associate Professor Lee Usnick, JD I. ASSIGNMENT OVERVIEW Virtually all business activities conducted in the United States are highly regulated, not only by governmental entities, but by professional entities as well. Compliance with all federal, state, and local laws and regulations is a prerequisite to the long term health and survival of a business. Equally important is a business's compliance with standards issued by the professional and accrediting bodies responsible for licensing and certification. Certain industries are more regulated than others. For example, health care, financial services, and public utilities are all highly regulated with extensive licensing and operational standards. When a business fails to comply with all applicable regulations and standards, the business and the individuals who manage it can face a variety of sanctions, from loss of license and program certification, to civil and criminal sanctions that include monetary penalties and prison. In this assignment, you will learn how someone in your selected industry meets the challenges of current compliance requirements. It is not necessary to address all aspects of compliance in this industry or selected company. Rather, you should educate yourself in broad terms about the kinds of governmental and industry standards covering your interviewee's business, then select a few key aspects to explore in depth with...
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...BA 3301 Legal Environment of Business Compliance Interview and Report Assignment Associate Professor Lee Usnick, JD I. ASSIGNMENT OVERVIEW Virtually all business activities conducted in the United States are highly regulated, not only by governmental entities, but by professional entities as well. Compliance with all federal, state, and local laws and regulations is a prerequisite to the long term health and survival of a business. Equally important is a business's compliance with standards issued by the professional and accrediting bodies responsible for licensing and certification. Certain industries are more regulated than others. For example, health care, financial services, and public utilities are all highly regulated with extensive licensing and operational standards. When a business fails to comply with all applicable regulations and standards, the business and the individuals who manage it can face a variety of sanctions, from loss of license and program certification, to civil and criminal sanctions that include monetary penalties and prison. In this assignment, you will learn how someone in your selected industry meets the challenges of current compliance requirements. It is not necessary to address all aspects of compliance in this industry or selected company. Rather, you should educate yourself in broad terms about the kinds of governmental and industry standards covering your interviewee's business, then select a few key aspects to explore in depth with...
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...calling them partners would make them want to give the best customer experience that they can, to take pride in their work. Starbucks have kept true the statement by creating a culture that mainly focuses on customer satisfaction. Their partners (employees) thrive to improve the customers experience by relating to them and continue to provide excellence in customer satisfaction. The company and its partners constantly seek feedback on how to improve their customers experience in an effort to maintain the company’s standards. A form of internal communication Starbucks has is a program called the “Business Ethics and Compliance “(http://www.starbucks.com/, 2012) which is a program that continuously offers to teach and support the Starbucks Mission and protect their culture and the company’s reputation. This program reinforces the company’s ethics, legal compliance and ethics training to make sure the partners continue to offer their customers the best experience possible when visiting their establishments. A couple of internal communication is the program of Business Ethics and from requesting feedback from their customers shows internal and external communication to keep up with the...
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