Medicare and Medicaid Patient and Program Protection Act of 1987 - Assignment Example

Name Subject Professor Date The importance of the following government initiatives as they pertain to the coding function: Medicare and Medicaid patient and program protection act of 1987- the importance of coding function in this case is to ensure that there is proper documentation which will be used by a contracted contractor in carrying out audit to prevent fraud. The coding system is important when it comes to medical review by independent contractors in order to discover the authenticity of the claims made by individuals. It helps for quick medical review when there is a suspected accuse by both the patient and the medical facility. The medical facility may participate in fraud by billing the patient when services are not rendered. The medical review will review this: coding will help in carrying out progressive corrective action in case they have not been used properly. In case there is no proper coding funds released will be recovered Operation Restores Trust. - The coding system in this case is important as it will enable those individuals who have reported cases of fraud get rewarded. It encourages governance, accuracy, and proper documentation. Any party who has reported a fraud case will be rewarded by the facility and ensure that fraud does not occur again. Te coding system ensures that there is accuracy in the other codes especially those related to services for patients and medics given. Medicare integrity programme- Medicare integrity programme aims at ensuing there is proper documentations provided to patients in order to have high integrity. Without proper coding the funds can not release funds for any claims. It helps to prevent fraud and the abuse practices from dishonest individuals. Without this programme, inappropriate payments will be made which may lead to the insolvency of the organization. Therefore it helps reduce fraudulent and abusive claims, easier identification of fraud and easier detection of fraud. Alterations will also be noted if proper coding is not used. Medicare prescription drug improvement and modernization act of 2003: recovery demonstration project – the coding system here is critical to the success of the programme. It helps reduce outdated in formations and materials by making the medical facility remain current. It ensures that the medical facility are compliant with the rules, if the facility is not compliant with the rules then it means the medical facility is not following Medicare prescription drug improvement and modernization act of 2003: recovery demonstration project. The role of a quality improvement organization contracting under the Centers for Medicare and Medicaid Services as it applies to the coding process.   The main purpose of contracted organizations is to help in carrying out audit which will help in reducing misuse of the funds. In other words it should identify and stop fraudulent and abusive claims which are made by its honest individuals. They should also be in a position to reduce fraudulent cases. It is also supposed to establish standards and guidelines that will be used to govern medical review of claims. The standards and guidelines which are prepared by this organization are supposed to help in monitoring the compliance of rules and guidelines governing Medicare and Medicaid services. The contracted organization personnel are experts in studying patient safety events, and their tasks include identifying, studying, preventing and eradicating or lessening hazards and risks that the delivery of healthcare services may expose patients to. According to the AHRQ, there are eight patient safety activities that health care providers aim for: The enhancement of patient safety and the “quality of healthcare delivery;” The gathering and study of the Patient Safety Work Product; The creation and distribution of data pertaining to the safety of patients, including recommendations, procedures or knowledge on best practices; Learning how to use PSWP so that a culture of safety will be promoted, as well as mechanisms for giving feedback and help so that risk to patients are minimized; Measures to promote confidentiality; The retention of qualified personnel; and Undertakings associated with the usage of a “patient safety evaluation system” (Montoya, 2010, p. 213). It is important to understand at this point that the term “safety” refers to the reduction or eradication of patient risks from injury and harm while “quality” implies undertaking steps in order to attain enhanced value and excellence. One way of improving safety and quality is through the use of evidence-based practices. In a nutshell, EBP is a systematic procedure of applying the best evidence available to guide clinical practice. Evidence may come from different sources, including information from medical records, works on risk management and quality enhancement, and “findings from infection control, cost-analysis, and benchmark projects. So that EBP will be embraced in medical professionals’ everyday practice, organizational leaders must endeavor to establish a culture consisting of perpetual learning and clinical inquiry. Healthcare providers must design an organizational practice model that supports the creation of interventions founded on evidence. Diagram the activities of each step of the revenue cycle in the order in which they occur. The revenue cycle diagram has the following activities. Registration – When the patient arrives in a medical facility is registered to show the need of offering services to her. The HIM staff members will enter the patients data to the systems in terms of age, gender and medical plan the patient is subscribing to Scheduling – the patient is scheduled to need a doctor or a nurse who will offer services that the patient needs. The scheduling is done by HIM staff members because they know which patient is going to which doctor and how many patients the doctor has.   Charge capture- after the patient has seen the doctor, he will bring prescriptions from the doctor to HIM staff who will capture the details of the treatment thereafter indicate the cost or the charges the patients should pay. The patient will be advised accordingly, and then he produces the card for his medical insurance plan as well as his identification. Coding and documentation – the documents produced by the patient including those given by the doctor are coded by one of the HIM staff members. These are the people who will produce documentation that will be used by the medical facility in making claims. Claims processing - claims processing will beginning immediately documentation and coding is done. HIM will give the documents to finance to start the process of claims processing. Managed care contracting – after claims processing the organizations will contact the organizations which are responsible for determining the authenticity of the documents presented by the documents. Denial management – the patients will be denied the ability to use his card if it is not genuine and it will be asked to prod ice cash for the Services’ rendered to him. Payment posting – if the patient documents are correct payment are posted in the books of accounting and the HIM staff members are notified to update their records. Revenue follow up – the financed department makes a follow up to insurance medical provide in order to collect their revenues. Collections - the revenue is collected in terms of cash, cheque or other means Reporting and bench marking – a report is prepared to show the position of collections and collection that have been denied. Automated billing report errors: The date of service on one portion of the bill for a same-day surgery was not in agreement with the date on other portions of the bill – investigations will be carried out to determine whether there is loss of revenue because of this error it will be recovered from the parties involved. However such an error is corrected and relevant departments notified for corrective action. The diagnosis and procedural codes were inaccurate – in this case, the codes needs to be rectified and the patient should be notified. If by any chance the patient had been affected by improper diagnosis and procedural codes then proper corrective measure should be corrected but the system errors. If fraud is noted then the staff involved will be punished accordingly. Although the damage is irreparable, the situation leads to certain corrective measures that should be done to prevent a reoccurrence. An improvement plan is needed that would institute changes in the processes, particularly in the competencies and attitudes of the nurse. A procedure was billed to the wrong patient – in this case there is need to have a corrective measure which will help the patient have proper procedure assigned to him. First the documents of the two patients will be retrieved then proper billing is done then relevant departments are noted. This will mean that if claims had been made a credit will be shown in the accounts which will be offset in the future. If clams had not been made then proper claim will be processed. Works Cited Brett, Allan. “New Guidelines for Coding Physicians’ Services—A Step Backward,” New England Journal of Medicine, 339, no. 23 (December 3, 1998): 1705-1708. Matherlee, Karen from Diagnosis to Payment: The Dynamics of Coding Systems for Hospital, Physician, and Other Health Services. NHPF Background Paper. Jan. 2002. 29 Oct. 2012 < http://www.nhpf.org/library/background-papers/BP_Coding_1-02.pdf> Miller, Evans., & Mor, Vane. (2008). Balancing regulatory controls and incentives: Toward smarter and more transparent oversight in long-term care. Journal of Health Politics, Policy & Law, 2008, 33 (2), 249-279. Montoya, Ivan. (2010). Patient safety and quality improvement: A policy assessment. Clinical Laboratory Science, 23 (4), 212-218. NHIC, corp., 2010. Fraud & Abuse Billing Guide. Jul. 2010. 29 Oct. 2012 Read More