Question

You have been hired as the chief compliance officer at UCF Medical Center.  The Medical Center has received 100 denials for inpatient medical necessity from Medicare in just the past few months.  You have reviewed the records as well as the appeal letters that were submitted previously, which resulted in 56 of the cases being overturned on appeal (this means that 44% were denied).  Two physicians are noted to have 18 of the cases, but the remainder come from a variety of physicians and services.

Create a corrective action plan for EACH of the following four areas of concern and note that each area should be addressed with 100-200 words.  Eight points per plan.  Each plan must include who should be involved (be as specific as possible).  Keep in mind that HIM professionals must work with other hospital personnel to solve these issues (including medical staff) but everyone does not need to be involved in each issue. Actually, its possible that other department heads should take the lead on one or more of the issues!  It is important for you to understand the roles that various people in healthcare perform so think about this carefully as you develop the corrective plans for the Medical Center.  Discuss meetings to be held, processes to be changed, continuing education that may be required, who would be involved, etc.  How will you handle the two physicians who have numerous denials (eight points)?  Upload a Word document, please check your grammar and put your plan though Spell Check first! The document will be evaluated through turnitin.com.

Failure to issue Advanced Beneficiary Notice:  3 cases

Patient admitted to inpatient status rather than observation:  9 cases

Inadequate documentation: 39 cases

Lack of medical necessity:  49 cases

Answer 1

Chief compliance officer of a company it the officer primary responsible for over seeing and managing regulatory compliance issues with in the Organization.Chief compliance officer directly inform or report to Chief executive officer of company.

Daniel is missing or incorrect information or duplication of records.

Some of the denials in medical department (Billing and coding )are: Missing information,duplicate claim services,not covered by payers,limit for filling expired,service already adjucate.

1.Meetings to be held: To correct or to prevent denials some of the meetings to be held

Those are: a.Root cause determination.: Root cause determination done by a assessing all the denial cases documents.

b.Make prioritization based on eligibility.:based on the severity of the denial make prioritization of case.

c.meeting about quality maintenance. Maintenance of quality in care ,procedures and documentations will help to reduce denial.

d.preparation of preauthorization and medical necessity.

e.Meeting about claim processing.Discussion about the claim processing based on claimers policies.

f.discussion about ongoing analysis across the revenue cycle.

2.Process to be changed: An ounce of prevention pays off.so while effecting process change in an always busy practice can be daunting ,some often simple operational process chamges can ultimatelysave you both time and money.There are six areas that can make significant improvement in prevent denials

A.Educate an communication. Continuing education is needed.

B.Verify insurance prior to service : Its essential need for early verification of eligibility can't be overstated in health care financial.

C.Know your payer:This is complex but critical area.Having a close relationship with your key payers makes it far easier to understand current and evolving rules for medical necessity ,prior authorization,referrals and more

D.Accurate and appropriate Documentation: With the much greater complexity of ICD 10 coding ,more specifically than ever is essential in your documentation.

E.Leveraging technology: Investing in practice management and /or Electronic health Care record system is expansive and time consuming.Changes has to made in this

F.Learning from mistakes avoid future ones..Effective constant change starts at the top.

3.Continuing Education :Continuing education required to protectively prevent denials.

Education and communication: Internal and external communication is typically key to the success of any business,and in the ever changing health care industry,it's certainly no change.It is essential That team members understand their roles and responsibility .Continuing education should be provided on Documentation,key elements,,proper coding plans,each insurance plans,their co pays and deductibles ,and most important Icd coding system.its again worth saying continuing education and continuously update certification to keep every member of your team knowledgeable about the latest health care changes.

4.Handling Physicians done denials.Malpractice insurance through occurrence coverage,claim made coverage should be done ..

Continuing education should be provided for physician.

Team members: Chief Compliance officer ,person from coding,billing ,staff nurse,physician.