...Part II POLICIES AND PROCEDURES FOR THE PHYSICIANS’ INJECTABLE DRUG LIST GEORGIA DEPARTMENT OF COMMUNITY HEALTH DIVISION OF MEDICAL ASSISTANCE PLANS Published October 1, 2013 PREFACE The Physicians’ Injectable Drug List (PIDL) manual contains basic information regarding Georgia’s Fee for Service (FFS) Medicaid and PeachCare for Kids programs and should be used in conjunction with Policies and Procedures Manual for Medicaid and PeachCare for Kids Part I, Part II Policies and Procedures Manual for Physician Services, and other applicable program manuals. We urge you and your office staff to familiarize yourselves with the contents of this manual and refer to it when questions arise. Use of the manuals will assist in the elimination of misunderstandings concerning the coverage levels and billing procedures that can result in delays of claims processing or payments, inaccuracies and/or denials. The PIDL is reviewed and updated quarterly, it is re-priced annually. Drugs that are not re-priced by the manufacturer or are no longer manufactured, or obsolete may not be re-priced or changed— refer to the Schedule of Maximum Allowable Payments (Appendix A) in this manual. For quality purposes, the PIDL is periodically purged of drugs with no or low (fewer than 50 units of service annually) utilization over a three (3) year period; except for orphan drugs and certain chemotherapeutic agents. Requests for coverage of purged drugs will be considered on a case-bycase...
Words: 9265 - Pages: 38
...Dealing with Fraud Liquid Professor Beharry Health Care Policy, Law, and Ethics March 18, 2013 Abstract This paper will evaluate how the Healthcare Qui Tam affects health care organizations while providing (4) examples of Qui Tam cases that exist in a variety of health care organizations. Other responsibilities discussed, are devising a procedure for admission into a health care facility that upholds the law about the required number of Medicare and Medicaid referrals; the ability to recommend a corporate integrity program that will mitigate incidents of fraud and assess how the recommendation will impact issues of reproduction and birth. The know how to devise a plan to protect patient information that complies with all necessary laws. Evaluate how the Healthcare Qui Tam affects health care organizations. The Healthcare Qui Tam affects health care organizations in that well over more than 450 hospitals across the country were the subject of Medicare fraud investigations. Whether or not Medicare violations are found, the costs of responding to an investigation can be significant. Westchester Medical Center of New York, being investigated for possible health care fraud and violations of anti-kickback laws, received a subpoena for extensive records in some thirty-seven categories going back to 1997. Millions of dollars may be spent in legal fees and other costs associated with the investigation (e.g., hiring or reassigning staff to assist with compiling...
Words: 2629 - Pages: 11
...HIPPA Joe Smith Independence University HCA 542A Mod 11:2011 8wk-online Final Paper October 10, 2011 HIPPA This paper will begin with a brief background and history on the Health Insurance Portability and Accountability Act (HIPAA). Following the background will be details about issues that are address within the Health Insurance Portability and Accountability Act. The purpose of this paper is to provide a foundation with providing some information about HIPAA. Background The Health Insurance Portability and Accountability Act (HIPAA) was enacted by Congress in 1996 in response to several issues facing health care coverage, privacy, security and fraud in the United States (ALL THINGS MEDICAL BILLING, 2011, para. 2). Before HIPAA, rules and regulations varied by state, there was no real consistency. Also, there was confusion as to which regulations were applicable and to whom. Did the rules apply in the states where the organization was doing business or where the organization was based? There was also no uniformity between state and federal requirements (ALL THINGS MEDICAL BILLING, 2011, para. 3). With regard to privacy, there were numerous uncoordinated federal acts which addressed privacy in some form. Prior to HIPAA, there was no standard authority for enforcement of fraud and abuse that applied to state and federal health care programs (ALL THINGS MEDICAL BILLING, 2011, para. 4). Congress recognized the increased use...
Words: 2149 - Pages: 9
...automates a set of medical or surgical codes, based on clinical documentation from a healthcare provider, which is used for review and validation. With the assistance of these new automation tools, coding or HIM professionals can easily translate clinical data input into useful clinical data output. Increased amounts of clinical coding is done by machines, which saves time and human participation for more complex coding cases and data analysis tasks. Factors, such as advances in natural language processing, EHR adoption, compliance issues and mandates for labor – intensive administrative reporting processes reduction, influenced the demand of CAC. Traditionally, clinical documentation (whether paper or electronic) is analyzed by a coder, translated into the appropriate ICD – 9 CM or CPT/HCPCS codes with the help of coding books or encoders and entered into a database. These new coding automation tools assists HIM professionals in translating data by automated code assignment instead of manual review and translation alone. As early as the 1950s, the technology of CAC – enabled tools, particularly Natural Language Processing (NLP), started with formal language theory. Throughout this time, technological progress was slow but technology has rapidly progressed and is constantly advancing at an exponential rate since the 1990s. Coding is a difficult task because it has a four- dimensional complexity. First, coding rules’ volume and intricacy makes selecting the right diagnosis/ procedure...
Words: 2639 - Pages: 11
...respective owners. HP Enterprise Services is an equal opportunity employer and values the diversity of its people. © 2010 HP Enterprise Services. All rights reserved. Contents Introduction 3 Eligibility 4 Restricted Aid Categories 4 All Arkansas Medicaid Aid Categories 6 Therapy Benefits 10 Program Coverage 12 Prior Authorization Request Procedures for Augmentative Communication Device (ACD) 15 Evaluation 15 Contact List for Reviews, Managed Care and Authorizations 16 National Place of Service Codes 18 Quick Tips for Submitting Claims 19 Introduction to Billing 19 CMS-1500 Billing Procedures - Occupational, Physical, Speech Therapy Procedure Codes 19 Augmentative Communication Device (ACD) Évaluation 22 Billing Instructions - Paper Only 22 Completion of the CMS-1500 Claim Form 22 Special Billing Procedures 29 Common Billing Errors 30 Brief Overview of Benefits 31 Contact Information 32 Introduction This Billing Tips document serves as a training supplement for Arkansas Medicaid providers but does not supersede official program documentation including: Arkansas Medicaid provider manuals, Official Notices and transmittal letters published by the Division of Medical Services and distributed by HP Enterprise Services. This document focuses on Arkansas Medicaid eligibility and billing issues and incorporates the following quick reference items...
Words: 6485 - Pages: 26
...NAME: GRANT BARZDO MODULE: PARAMEDIC PLACEMENT EDUCATOR REFLECTIVE ESSAY TUTOR: KEVIN BARRET Introduction: This paper will be written in a reflective style which will utilise Gibbs reflective model (Gibbs, 1988). As a Paramedic Practice Placement Educator (PPEd) and health care professional it will enable myself learn from the experience (Bolton, 2014). This reflective essay will analyse and evaluate the feedback provided and how it was received by a student. Additionally, it will analyse and evaluate different types of feedback including different models used in the healthcare setting. Finally, I will further seek ways to improve this process for the future when giving feedback. Description: So as to comply with the Health and Care Professions council, PPEds must undertake appropriate practice placement educator training (HCPC, 2014). Hence, as part of the PPEd course it essential carry out the teaching of a skill, assess the student and give the student relevant feedback. This was all observed and assessed by a qualified PPEd. The skill I selected to teach was the preparation and insertion of a nasopharyngeal airway (NP) to a first year student. I prepared for this by finding out where the student was in their BSc paramedic degree course and to what level they knew about the skill. Additionally, I ensured that I had the correct equipment needed for the teaching sessions, as well as preparing an assessment sheet. At the beginning if the session I explained...
Words: 2913 - Pages: 12
...individuals filing of a dishonest health care claim in order to turn it into a profit. Abuse; however, is harder for the investigator to identify and establish if the act was committed knowingly, willfully, and intentionally. Healthcare industry is one of the fastest growing sectors of the US economy; almost 10% of the US’s national GDP is consumed by the health care industry. According to Forbes’s report, the US National Healthcare expenditure of 2012 was nearly $3 Trillion. According to the National Healthcare Anti-Fraud Association, nearly $60 Billion is lost to healthcare fraud each year. The healthcare industry is an enormous market; therefore, making it easier for healthcare providers to take advantage of the American population. This paper will focus on why fraud and abuse occurs, different types of fraud, example cases of fraud and abuse, impact to present day healthcare industry, and potential solutions to fixing and preventing fraud and abuse from occurring. According to Hawaii Medical Service Association (HMSA), “Health care fraud occurs when a person or business intentionally misrepresents facts to receive reimbursement for health care services or supplies. It is a criminal offense under state and federal laws and can result in hefty fines, loss of health care coverage, and/or criminal penalties, including jail time.” For an example,...
Words: 4007 - Pages: 17
...HIM141 Test 4 Chapters 8-10 Please completely answer the following questions. 1. What is the MPI and what types of information are contained in the MPI? MPI-master patient index, sometimes called a master person index, link a patient’s medical record number with common identification data elements, for example: patient’s complete name, date of birth, gender, mother’s maiden name and social security number. Because most health care facilities house patient records according to a medical record number, the MP becomes the key to locating paper based records in the health information department file system. Thus, the MPI is retained permanently because it serves as the key to finding the patients record, it can be automated or manual. According to the American Health Information Management Association (AHIMA), some recommended core data elements for indexing and searching records include: * Internal patient Identification * Patient Name * DOB * DOB qualifier * Gender * Race * Ethnicity * Address * Alias/pervious name * SS# * Facility identification * Universal patient identifier (if available) * Account number * Admission date * Discharge date * Service type * Patient disposition 2. What are registers and indexes? Registers and registries contain information about a disease or event and are maintained by individual health care facilities, federal and state government agencies and private organizations...
Words: 3684 - Pages: 15
...Diabetes Working Group White Paper Avalere Health LLC on behalf of the Diabetes Working Group January 23, 2012 Table of Contents Authors.......................................................................................................................................... 3 Acknowledgments ......................................................................................................................... 4 Executive Summary ...................................................................................................................... 5 Provider Survey ......................................................................................................................... 6 Standards of Care Economic Model .......................................................................................... 7 Recommendations .................................................................................................................... 8 Care Management ................................................................................................................................ 8 Payment Reform ................................................................................................................................... 9 Workforce Supply ............................................................................................................................... 10 Background and Role of the Diabetes Working Group ............................
Words: 18881 - Pages: 76
...#1…Public health IN THE United States, primary care remains a medical model. This is in contrast to much of the world, where the 1978 Declaration of Alma-At a which recognized that attaining health for all also requires interaction from social and economic sectors - is considered standard. Today, there is much buzz about patient-centered medical homes, a concept that promises to transform the practice of American medicine. There is much to praise about this most recent iteration of the medical home. But the missing ingrethent in all these definitions and models remains public health. A population focus that addresses the social determinants of health is an essential component of primary health care. In the United States, such a comprehensive approach has been labeled community-oriented primary care. This model is built firmly on the Alma-Ata principles and incorporates a public health approach to health services. Community-oriented primary care organizes the delivery of health services, around a population, not simply a collection of individuals. It identifies a population - most frequently a geographically defined community - and uses epidemiology and interventions to improve community and individual health and well-being. In this model, both individual patients and the community are the foci of the delivery of health services. Primary health care stands at the intersection of personal and population health services. It requires integrating medical models of primary care...
Words: 12713 - Pages: 51
...0 3 0 Electronic Health Records in the Physician Office CHAPTER OUTLINE Patient Flow in the Physician Practice Step 1. Pre-Visit: Appointment Scheduling and Information Collection Step 2. Patient Check-in and Payment Collection Step 3. Rooming and Measuring Vital Signs Patient Examination and Documentation Step 4. Patient Checkout Step 5. Post-Visit: Coding and Billing Post-Visit: Reviewing Test Results Coding and Reimbursement in Electronic Health Records Computer-Assisted Coding Clinical Tools in the Electronic Health Record Decision-Support Tools Tracking and Monitoring Patient Care Screening for Illness or Disease Identifying at-Risk Patients Managing Patients with Chronic Diseases Improving the Quality and Safety of Patient Care with Evidence-Based Guidelines E-Prescribing and Electronic Health Records Keeping Current with Electronic Drug Databases Increasing Prescription Safety Saving Time and Money LEARNING OUTCOMES After completing this chapter, you will be able to define key terms and: 1. 2. 3. 4. 5. 6. 7. 8. 9. List the five steps of the office visit workflow in a physician office. Discuss the advantages of pre-visit scheduling and information collection for patients and office staff. Describe the process of electronic check-in. Explain how electronic health records make documenting patient exams more efficient. Explain what occurs during patient checkout. Explain what two events take place during the post-visit step of the visit workflow. Describe the advantages of computer-assisted...
Words: 12974 - Pages: 52
...0 3 0 Electronic Health Records in the Physician Office CHAPTER OUTLINE Patient Flow in the Physician Practice Step 1. Pre-Visit: Appointment Scheduling and Information Collection Step 2. Patient Check-in and Payment Collection Step 3. Rooming and Measuring Vital Signs Patient Examination and Documentation Step 4. Patient Checkout Step 5. Post-Visit: Coding and Billing Post-Visit: Reviewing Test Results Coding and Reimbursement in Electronic Health Records Computer-Assisted Coding Clinical Tools in the Electronic Health Record Decision-Support Tools Tracking and Monitoring Patient Care Screening for Illness or Disease Identifying at-Risk Patients Managing Patients with Chronic Diseases Improving the Quality and Safety of Patient Care with Evidence-Based Guidelines E-Prescribing and Electronic Health Records Keeping Current with Electronic Drug Databases Increasing Prescription Safety Saving Time and Money LEARNING OUTCOMES After completing this chapter, you will be able to define key terms and: 1. 2. 3. 4. 5. 6. 7. 8. 9. List the five steps of the office visit workflow in a physician office. Discuss the advantages of pre-visit scheduling and information collection for patients and office staff. Describe the process of electronic check-in. Explain how electronic health records make documenting patient exams more efficient. Explain what occurs during patient checkout. Explain what two events take place during the post-visit step of the...
Words: 12974 - Pages: 52
...ram4577X_ch03.qxd 4/16/04 11:50 Page 37 Legal and Ethical Issues in Medical Practice, Including HIPAA AREAS OF COMPETENCE 2003 Role Delineation Study CLINICAL Fundamental Principles ɀ Apply principles of aseptic technique and infection control ɀ Comply with quality assurance practices Patient Care ɀ Coordinate patient care information with other health-care providers GENERAL Legal Concepts ɀ Perform within legal and ethical boundaries ɀ Prepare and maintain medical records ɀ Document accurately ɀ Follow employer’s established policies dealing with the health-care contract ɀ Implement and maintain federal and state health-care legislation and regulations ɀ Comply with established risk management and safety procedures ɀ Recognize professional credentialing criteria CHAPTER OUTLINE ɀ ɀ ɀ ɀ Medical Law and Ethics OSHA Regulations Quality Control and Assurance Code of Ethics ɀ HIPAA ɀ Confidentiality Issues and Mandatory Disclosure OBJECTIVES After completing Chapter 3, you will be able to: 3.1 Define ethics, bioethics, and law. 3.2 Discuss the measures a medical practice must take to avoid malpractice claims. 3.3 Describe OSHA requirements for a medical office. KEY TERMS abandonment agent arbitration assault authorization battery bioethics breach of contract civil law contract crime criminal law defamation disclosure durable power of attorney electronic transaction record ethics expressed contract felony fraud ...
Words: 15296 - Pages: 62
...ALLIED AMERICAN UNIVERSITY Personalized. Flexible. Dedicated. Online Programs – Individual Support – Open Enrollment – Ease of Transfer Credits UNIVERSITY CATALOG 2013 Seventh Edition 22952 Alcalde Drive, Laguna Hills, CA 92653 Phone: (888) 384-0849 ∼ Fax: (949) 707-2978 7:00 A.M. – 5:00 P.M. (Monday – Friday) Email: info@allied.edu Website: www.allied.edu KEY STAFF AND FACULTY Charlotte Hislop, Ph.D. Candidate, President/CEO Bonny Nickle, Ed.D., Provost Eric Sharkey, M.Ed., Director of Education Bill Luton, Ph.D., Director of Assessment and Dean of Business Carlo Tannoury, Ph.D. Candidate, Dean of Computer Information Systems Patricia Drown, Ph.D., Dean of Criminal Justice and General Studies C.J. Bishop, M.B.A., Institutional Research Frank Vazquez, Operations Director Parrish Nicholls, J.D., Director of Compliance Lindsay Oglesby, Admissions Director Abby Dolan, B.A., Registrar Sasha Heard, M.B.A., Student Services Manager Barbara Jobin, B.S.B.A., Career Center Manager Hugo Aguilar, B.A., Chief Financial Officer Richard Madrigal, B.A., Financial Aid Officer As a prospective student at Allied American University, you are encouraged to review this catalog prior to signing an enrollment agreement. You are also encouraged to review the student performance fact sheet which must be provided to you prior to signing an enrollment agreement. This catalog is not a contract between the student, AAU, or any party or parties. Reasonable effort was made at the time this document...
Words: 52297 - Pages: 210
...ork2012 - 2013 Catalog A Message from the President “Sullivan University is truly a unique and student success focused institution.” I have shared that statement with numerous groups and it simply summarizes my basic philosophy of what Sullivan is all about. When I say that Sullivan is “student success focused,” I feel as President that I owe a definition of this statement to all who are considering Sullivan University. First, Sullivan is unique among institutions of higher education with its innovative, career-first curriculum. You can earn a career diploma or certificate in a year or less and then accept employment while still being able to complete your associate, bachelor’s, master’s or doctoral degree by attending during the day, evenings, weekends, or online. Business and industry do not expand or hire new employees only in May or June each year. Yet most institutions of higher education operate on a nine-month school year with almost everyone graduating in May. We remained focused on your success and education, and continue to offer our students the opportunity to begin classes or to graduate four times a year with our flexible, year-round full-time schedule of classes. If you really want to attend a school where your needs (your real needs) come first, consider Sullivan University. I believe we can help you exceed your expectations. Since words cannot fully describe the atmosphere at Sullivan University, please accept my personal invitation to visit and experience...
Words: 103133 - Pages: 413
