...The given “Healthcare Compliance and Coding Management Effectiveness Scenario” describes the day to day challenges that a Health Information Management (HIM) department Manager/Supervisor will face. In this case it is actually a newly hired HIM department’s Manager/Supervisor. My approach to address the challenges presented in the scenario would be to first access and analyze the current workforce that I am responsible to manage, evaluate the new requirement that has to be fulfilled as a result of acquisition of the new clinic, and finally make decisions based on the qualifications, standards and requirements of the required workforce, taking into account the productivity and quality of work at both the hospital and the newly acquired clinic. In the given scenario there is currently a rural hospital and an outpatient setting. Apart from these 2, the organization has also acquired an outpatient clinical setting 50 miles from the hospital which has contracted a local lumberyard and small farm equipment manufacturing plant in town to provide medical services for injured workers. In the hospital setting there are 3 coders who take care of inpatient coding services, one front office employee who takes care of the paperwork, phone calls, release of information, and filling and retrieving of health records from various hospital departments. One of the coders also performs coding services for the outpatient setting that is attached to the hospital. In the newly acquired outpatient clinical...
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...discussed in this scenario is actually a very recently hired HIM manager for a rural hospital in the area. There are is a couple different approaches I would take in order to handle this situation to the best of my ability. The 1st step I would take is to look at the current individuals I am managing, and overall analyze their position at the hospital. I need to be fully aware of their exact duties, and analyze in detail things about each position. The 2nd step I will need to do is look at the outpatient clinic position, and see exactly what is required for this clinic. Next I will need to make a decision on who will be the best candidate to fulfill this position based on the overall work requirements, and qualifications needed for this position. I need to make a decision that overall positively affects both the hospital, and new outpatient clinic. A1. The hospital in this scenario is located in a rural setting. The hospital has recently purchased a small outpatient clinic that is approximately 50 miles from the hospital. Currently about 20-30 patients are seen daily by one provider at the clinic. The hospital does have a contract with several different businesses to provide care for workers injured at work. So let’s analyze my current staff: * 3 coders who take care of the hospital coding (1 of these coders does the coding for the outpatient clinic attached directly to the hospital as well) * 1 front office employee- this employee answers phones, takes care of patient...
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...Healthcare Compliance and Coding Management Task 1 A. Discuss how you would carry out your various responsibilities as a coding manager by doing the following: A1. Analyze the job description for an inpatient coding position Managers should be aware of skill sets needed for an HIIM workforce, and recruit qualified staff to fulfill new job roles. Manager should review the job description each time they have a recruitment opportunity. They need to ensure the description outlines the work to be performed. It should be specific to the role of Inpatient Coder. The job description needs to include the position requirements, purpose, and all functions. It should also list the qualifications needed to be hired and successful. Sections of the description should also include education level, years of experience, specific knowledge needed, and any specific proficiency needed for the job. Be specific, before posting a job. Specification helps to minimize the wasted time and effort of the interviewer and interviewee. One of the Inpatient coder’s responsibilities would be reviewing all patient files for accuracy and recording into the computer; therefore a couple of key qualifications that should be listed would be, attention to detail and has medical terminology background. (Wilson, Jacqueline) Job descriptions are used by the manager to clearly set employee expectations for job performance. A2. Develop goals for a clinical documentation...
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...Compliance and Coding Management Task 2 Western Governor’s University Compliance and Coding Management Task 2 A. Outline a HIM compliance plan that emphasizes the coding function by doing the following: 1. The necessary components of a compliance plan include Code of conduct, policies and procedures, education and training, communication, auditing, corrective action and reporting. The code of conduct is a statement or oath that establishes the intent to perform duties lawfully and ethically. The second component of a plan would include policies and procedures. The policies and procedures for coding would cover items such as how and when to query a physician, acceptable documentation sources, how to rebill a claim, usage of coding guidelines, payer specific issues, and any additional gray areas that may arise in the coding function. Education and training processes must also be outlined in a HIM compliance plan. This would need to identify the number of mandatory CEU’s for each employee, new hire training guidance and requirements, as well as physician and clinical staff educational guidelines and processes. The HIM/Coding compliance plan should also include policies and procedures that address communication, the auditing/monitoring process, any necessary corrective action steps and finally the process for reporting the coding compliance steps that have been followed and any areas identified as risks or any findings of noncompliance. 2. The HIM director...
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...My plan is to bring the hospital‘s AR Days back in line. This plan will need cooperation from the Medical Staff, the clinical departments, Health Information Management, Business Office and many others. Before I write my plan, I will need: a List of transactions with dates and maturity; information on our debtors as well as any information we collected on them. My writtenn report will be given to the board of directors. With approval we will have this implemented with four weeks. This plan will require everyone within the accounts receivable area in the hospital is responsible for making sure that all demographic and billing information is complete as possible. It starts in the registration area. The registration area is generally where every patient begins their journey through the hospitals computer system. It is very important for our employees to take the time to collect as much information as they can from the patient when the patient first presents for service. For the AR plan to work we will need to work with the Human resource and business office manager to implement a training session for all employees that work in admission especially the employees that work in the evenings. The training session should including education on what questions to ask. What documentation to ask patients for and more. How to make photocopies. After the original training, supplemental online training course should be implemented. Employees will be required to complete online tutorials...
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...#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...
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...INTRODUCTION This plan is an integral part of North Side’s ongoing efforts to achieve compliance with federal and state laws relating to billing for clinical services. The Plan creates a comprehensive and centralized system of oversight for bill coding, education, chart review, reporting and discipline (“Discipline,” as used throughout this policy shall include all steps described in the Human Resource policy manual and faculty policies and regulations including, without limitation, termination and tenure revocation). This Plan provides for oversight by a Compliance Program Medical Director and Compliance Officer. Although the intent is to encourage compliance through a centralized audit system, it remains the responsibility of each individual involved with the billing process, from physicians and other providers to clerical staff, to comply with the law. The purpose of this Plan is to ensure that clinical services are adequately documented and that properly coded bills are submitted only for documented services. This Plan is to be read in conjunction with and is an integral part of the University of Rochester Medical Center Compliance Plan, which is set forth in a separate document. In addition, it is anticipated that individual departments of the University will create specialty-specific billing compliance plans, which will be subject to review by the Compliance Program Medical Director and Compliance Officer. The University acknowledges that this plan is only the beginning...
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...Coding Compliance: Practical Strategies for Success by Sue Prophet, RRA, CCS, and Cheryl Hammen, ART -------------------------------------------------------------------------------- "Fraud," "abuse," "upcoding," "unbundling," and "compliance" have all become buzzwords in the news media. Eliminating healthcare fraud and abuse has become a top priority for the federal government. Government investigations are on the rise and providers everywhere tremble at the thought of becoming the next investigative target. An Office of Inspector General (OIG) audit of the Health Care Financing Administration (HCFA) revealed errors in 30 percent of all claims paid by HCFA in fiscal year 1996.1 These errors account for approximately $23.2 billion annually, or 14 percent of total Medicare fee-for-service (i.e., excluding managed care) payments. About half of the errors identified resulted from insufficient or lack of documentation from providers, and one-third of the documentation errors were associated with providers who failed to respond to repeated requests from auditors to submit documentation. The breakdown of the types of errors resulting in the improper payments is as shown in Figure 1. Breakdown by type of provider is shown in Figure 2. Figure 1 Insufficient/No documentation 46.76% Lack of medical necessity 36.78% Incorrect coding 8.53% Nonconverted/ Unallowable service 5.26% Other 2.67% -------------------------------------------------------------------------------- ...
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...Running head: Evaluating Compliance Strategies Assignment: Evaluating Compliance Strategies Name Axia College of University of Phoenix HCR 220 Date “Guidelines established by the healthcare staff and laws established by HIPAA are what make up the compliance process. These laws and guidelines were established to protect the patients, physicians, and staff members” (U.S. Dept. of Health and Human Services, n.d.). Errors in the office can be avoided by having a compliance process in effect. Using updated billing and coding software will help reduce errors made in the billing process. I agree with having a guide consisting of codes to aid in the billing process. I do regard this as cheating rather, to be used as a guide. Many offices currently have sheets that are located on the front of the patients’ file with the diagnosis and the code next to the diagnosis which the physician fills out. This eliminates an unnecessary step in the billing process and is a quicker, easier, and more accurate way to avoid errors. “In order to avoid rejection of the claim, it is important that the diagnoses and procedures are correctly linked” (AAFP, 1999). This also ensures that the claim is paid for the correct procedure performed by the physician. If an incorrect procedure was billed this could result in a loss of money by the physician for the type of procedure that was performed. The claim will have to be adjusted and resubmitted...
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...History and Future Of Medical Coding and Billing John F. McMahon BU480, Central Methodist University Abstract Medical coding and billing affects everyone during their lifetime and yet the regulations of medical coding and billing are extremely complex. Examining the history, evaluation, and effect of new regulations and their cost shed light on an already complex industry. We will review government regulations, technological advancements, and requirements that providers will face in the near future. We will examine our current systems and how they evolved through time and what they may be in the future. We have reviewed articles from the Medical Billing and Coding Association, the Department of Human and Health Services as well as the Office of the Inspector General. We will review the different types of insurance, how they each affect the process of medical coding and billing and then see what the future will be. Finally we will review what steps we have taken that has allowed a government to be so involved in our healthcare decisions. Thesis Statement Medical Coding and Billing has evolved to a point that it affects everyone at one time or another during their lifetime and has only led to complex rules and regulations that you almost need a degree to understand. From times that Physicians bartered for their services to the government telling them what to charge and insurance companies...
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...job functions of the current staff. Coders A coder is an individual that examines patient medical records and finds any diagnoses, treatments/medicines given, diagnostic testing, and so forth and gives each of these incidences a numerical (sometimes alphanumeric) value that is universal across insurance companies to collect payment for services rendered. Inpatient Coder- An inpatient coder is an individual that initiates requests for payments and reimbursement for procedures performed on a patient during a hospital stay on behalf of the medical facility. Inpatient Coders will deal more with ICD-9(10) or Diagnosis Codes than with CPT Procedure Codes. Inpatient coding could be considered to be more complex than outpatient coding because of the vast possibilities of different diseases, encounters and procedures. Outpatient Coder- An outpatient coder is an indiviual that initiates requests for payments for procedures performed either in a doctor's office or hospital outpatient department. Any procedure performed that does not require for the patient to stay more than 24 hours is considered outpatient. Outpatient coders typically deal more with CPT Procedure codes versus ICD 9(10) Diagnosis Codes. Outpatient coders that operate within doctor's offices are usually exposed to the same codes on a regular basis which is why many inpatient coders start off in an outpatient setting. Front Office Clerk The front office clerk is a job title that can differ in many different office...
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...patients p2 Establish financial responsibility St ep 3 S te p 9 Generate patient statements Check in patients Monitor payer adjudication Review coding compliance St ep 8 S te Check out patients Review billing compliance p7 St ep 5 S tep 6 Learning Outcomes After studying this chapter, you should be able to: 1.1 Explain how healthy practice finances depend on correctly accomplishing administrative tasks in the medical office. 1.2 Compare coinsurance and copayment requirements for health Copyright © 2014 The McGraw-Hill Companies plan benefits. 1.3 Identify the key steps in the medical billing cycle. 1.4 Discuss the impact of electronic health records on clinical and billing workflow. 1.5 Evaluate the importance of professional certification and of medical liability insurance for career advancement. S te p4 Medical Billing Cycle Prepare and transmit claims 1 accounts payable (AP) accounts receivable (AR) benefits cash flow certification coding coinsurance copayment covered services deductible diagnosis documentation electronic claim (e-claim) electronic health record (EHR) fee-for-service health care claim health information technology (HIT) health plan indemnity plan managed care managed care organization (MCO) medical assistant medical billing cycle medical documentation and billing cycle medical insurance medically necessary noncovered...
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...Jenny Windler Student ID: 000329547 Accreditation Audit (AFT2) Task 1 A. Compliance Status Nightingale Community Hospital is a complete and leading healthcare facility that believes in providing the best quality care to all of their patients. As part of Nightingale’s mission to put the patient first, the hospital must meet medication management standards set forth by the hospital and the Joint Commission. Medication management often involves the efforts of multiple services and disciplines. It is part of Nightingale’s policy that a patient’s information is accessible to a physician, pharmacist or nurse in the management of a patient’s medication. Nightingale Hospital has all the policies in place that the Joint Commission looks for to keep the hospital accredited. A1. Plan for Compliance In reviewing the safety of using medication associated with Anticoagulation Therapy, Nightingale Hospital needs some improvement. There was only one month out of the year that patients did not experience any adverse effects related to Anticoagulation Therapy. Numbers were high at the beginning of the year and tapered off by the end of the year, but Nightingale Hospital should be experiencing more months where there are no adverse events. In combination to the Joint Commission’s finding 2 years ago regarding the lack of documented evidence that the patient’s ability/readiness to learn, learning preference, or educational needs were assessed and documented in the file, we have much...
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...information and helps to identity the patient to ensure the patient safety. This is an important step especial for reoccurring patients... This step also helps with verifying a patients insurance. Pre-registration gives the office ample time to answer questions before they are asked by looking into the EHR. Pre-registration also allows you to see procedures that may require prior authorization (pre-cert). 2 Establish financial responsibility- Establishing financial responsibility is knowing who owes what for a certain doctor’s visits. Once the clinic gathers the pertinent information from the patient, then the biller can then determine which services are covered and allowed under the patient’s insurance plan. Insurance coverage can differ hugely between companies, individual, and plans, The biller needs to make sure each patient’s coverage in order to create the bill correctly. This also goes for prescriptions, some insurance companies do not allow for certain types or prefer generics. 3 Check in patients- Patient check-in and check-out are pretty much straight-at the desk task. When the comes in, First time patients will be asked to fill out paper forms or confirm the information the doctor has on file. The patient should be asked to verify ID and provide an insureance card. Some providers will receive a copy of the check in. 4 Check out Patient- When the patient is checked out, the medical report from that patient’s visit is sent to the medical coder, who will decode and translate...
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...Need for Teams Samantha Smith Need for Teams Background Goals and Objectives: The objectives for the first years of operation include are to include creating a medical call center that will be improved and have better customer service as well as exceeding the patients' expectations. Our agents will provide high-quality healthcare advice, products or assistance to residents of the area. We will serve our community’s needs. Forming a health care facility that fully capable to survive on its own cash flow within 10 months or less. To increase the number of call volume by 50% per year through improved customer service. To establish a creative website that includes online booking capability, as well complete information about the practice, hours, demographic information, health information and much more Mission The mission of the call center is to create the health and wellness of the local people by providing them with access to high-quality medical care for people young and old. The center is committed to providing these services exceed the expectations of each our patients, resulting in a successful and respectable business. Keys to Success Patients are the key to making the healthcare function. The call center main focus is on patient care. Educating the patients on the importance of preventative care helps prevent other diseases from taking over their bodies. Giving the patient their yearly checkup allows the doctor to discover if they educate patients. Figure out...
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