...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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...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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...#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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...Running Head: Fraud and Abuse Fraud and Abuse in the U.S. Healthcare System Tenisha Howard Keller Graduate Professor Cutspec June 12, 2011 Background People can be affected by healthcare fraud and abuse directly and indirectly. Fraud is defined as an intentional deception, false statement or misrepresentation made by a person with the knowledge that the deception could result in unauthorized benefit to oneself or another person. It includes any act that constitutes fraud under applicable federal or state law. Abuse is defined as practices that are inconsistent with professional standards of care; medical necessity; or sound fiscal, business, or medical practices. Intent is the key distinction between Fraud and Abuse. An allegation of waste and abuse can escalate into a fraud investigation if a pattern of intent is determined (B, Tom). Both, fraud and abuse can be committed by physicians, patients, and private insurers. Situations of fraud and abuse that occur in our healthcare system are billing for services that have not been provided, overbilling for services provided, and misdiagnosing health conditions in order to avoid financial responsibility for the proper treatment of illnesses. Define the Problem What can decrease the high costs of premiums and co payments? With the decrease of fraud and abuse, premiums and co payments would not be high. Who pays for fraud and abuse healthcare bill? Medicaid and Medicare are the two federal programs that are...
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...Chapter 1 Introduction to Professional Billing and Coding Careers MULTIPLE CHOICE 1. The percentage of all healthcare providers who are physicians and nurses is: a. 25%. b. 40%. c. 50%. d. 60%. Answer: b EMPLOYMENT DEMAND 2. The percentage of all healthcare providers who are allied health professionals is: a. 25%. b. 40%. c. 50%. d. 60%. Answer: d EMPLOYMENT DEMAND 3. The increased demand for medical billers, medical office assistants, and medical coders can be attributed to: a. the growth of managed care. b. physician practices having more responsibility for filing claims. c. the need for additional staff to file claims and work to obtain timely payment. d. all of the above. Answer: d EMPLOYMENT DEMAND 4. All of the following changes were a result of managed care EXCEPT: a. physicians having to wait 30 days or longer for payment. b. physicians having more responsibility for filing claims. c. patients having to pay for services when rendered. d. physicians having to add to their staff. Answer: c EMPLOYMENT DEMAND 5. Before the 1970s, a physician’s practice would grow based on: a. advertising and referrals. b. managed care contracts. c. consultations. d. hospital affiliations. Answer: a EMPLOYMENT DEMAND 6. Before the 1970s, a solo practice included all of the following staff members EXCEPT: a. physician. b. nurse. c. certified medical biller. d. receptionist. Answer: c EMPLOYMENT DEMAND 7. Managed care is...
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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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...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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...Correct Medical Billing and Coding in the Healthcare Industry Medical billing and coding is one of today's topics. When services are billed for patients, they must be coded based on the documentation the physician has dictated in the patients chart to receive payment from the insurance company. As the physicians office and/or hospitals practice correct medical billing and coding, this will prevent audits being brought forth in their practice and/or hospital. Kenny, Christopher,Correct Coding for Dialysis Billing Providers must ensure proper coding to avoid returned claim, 2012. This article is geared for those in the medical field who do coding and billing in hospitals for dialysis. The author is educating the coders and billers how to correctly code for dialysis billing. He mentions that The Centers for Medicare and Medicaid, issued a transmittal that has revised the Medicare claims processing manual as it pertains to hospitals billing for dialysis procedures that are non covered under the ESRD benefit for emergency dialysis. In addition, the author discusses how the hospitals should utilize Healthcare Common Procedure Coding System billing code G0275 and code 90935 for hemodialysis. Only to bill G0275, if the hospital is a ESRD facility, emergency services, and when dialysis is performed with related procedures, such as a vascular access procedures or when performed following treatment for an unrelated medical emergency. The author also continues to...
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...Public healthcare services are administered by different regulatory authorities in the United Arab Emirates. The Ministry of Health, Health Authority-Abu Dhabi (HAAD), the Dubai Health Authority (DHA) and the Emirates Health Authority (EHA) are the main authorities. Ministry of Health and Emirates Health Authority The Ministry administers a number of federal healthcare laws, including (i) Federal Law No. 5 of 1984 (regulating the licensing and registration of physicians, pharmacists and other healthcare specialists within both public and private healthcare establishments); (ii) Federal Law No. 7 of 1975 and Federal Law No. 2 of 1996 (defining the specific requirements for establishment and licensing of public and private medical laboratories, clinics and hospitals in the UAE); and (iii) Federal Law No. 4 of 1983 (governing pharmaceutical professions and establishments and the import, manufacture and distribution of pharmaceutical products). The Ministry oversees the Northern Emirates healthcare system (the Northern Emirates include Ras Al Khaimah, Ajman, Umm al Quwain, Sharjah and Fujairah). Some of the Northern Emirates recently started establishing new healthcare institutions or reforming existing ones. Sharjah, for example, established the Sharjah Health Authority by Sharjah Amiri Decree No. 12 of 2010. The Ministry, however, still invests substantial efforts to improve the level of healthcare services in the Northern Emirates. The projects announced...
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...is a small free standing clinic with under 25 beds. * Smiles clinic has on staff one IT/telephony expert, two coders and one billing administrative clerks. * IT/Telephony expert * Coding experts: * Submit claims in accordance with government regulations and private payer policies, follow-up on claim statuses, resolution of claim denials, appeals submission, posting of payments and adjustments, and collections management. * Coding professionals are expected to support the importance of accurate, complete, and consistent coding practices for the production of quality healthcare data. * Coding professionals in all healthcare settings should adhere to the ICD-9-CM (International Classification of Diseases, 9th revision, Clinical Modification) coding conventions, official coding guidelines approved by the Cooperating Parties,* the CPT (Current Procedural Terminology) rules established by the American Medical Association, and any other official coding rules and guidelines established for use with mandated standard code sets. Selection and sequencing of diagnoses and procedures must meet the definitions of required data sets for applicable healthcare settings. * Coding professionals should use their skills, their knowledge of currently mandated coding...
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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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...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 is that the medical...
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...Recommend a revenue strategy for the organization in the scenario to improve its revenue cycle management. Provide support for your recommendation. Patient Revenue Management solutions must efficiently manage the business of transforming patient care into positive financial outcomes. Clinical records must be linked with billing data to ensure proper reimbursements. Rules and embedded certifiable HIPAA EDI transaction sets must drive workflow. Medical billers are incredibly important in every healthcare facility— these providers can't stay in business without good billers. Traditionally, billers have either been trained on the job or have been medical coders who do both the coding and billing. However, the shortage of coders and the growing demand for skilled medical billing specialists has employers looking for professionals who know billing basics. Training with Career Step prepares you for a medical billing-specific career in much less time than it would take if you were gaining coding skills as well. As a medical billing specialist, you will take the data provided by the medical coders and use it to compile and submit claims to insurance companies and then subsequently bill patients. Day-to-day responsibilities vary from location to location, but often include: Using coded data to produce and submit claims to insurance companies Working directly with the insurance company, healthcare provider, and patient to get a claim processed and paid Reviewing and appealing unpaid and...
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...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 ways to inform your patients...
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...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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