HIM310 case study 3 and 5 final
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Case Study Three and Five- Claims Processing & Adverse Events in Skilled Nursing
Facilities
Ashton Henwood
HIM310: Healthcare Reimbursement
Instructor: Crystal Sayler
November 20, 2023
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The Centers for Medicare and Medicaid Services (CMS) administers and employs
Medicare contractors and programs, such as the Wisconsin Physicians Service (WPS), for
hospital outpatient claim payment and processing using the Fiscal Intermediary Shared System
(FISS). Through CMS's implementation of an outpatient prospective payment system (OPPS) for
hospital outpatient services, Medicare pays for hospital outpatient services on a rate-per-service
basis, varying according to its assigned ambulatory payment classification group. Under OPPS,
outlier payments are available when expensive services exceed payment thresholds. During an
outpatient procedure, common devices are used, including infusion pumps and
cardiac and joint
replacement devices, and typically only one is inserted. Any payments made to hospitals for
these devices are included in a payment package under the OPPS and must be reported along
with any related charges. It is critical to report devices used and related charges, as failing to do
so results in inaccurate outlier payments.
Chapter 3 - Claims Processing (Case Study One)
Upon review, the case study audit shows that between 2008 and 2009, $32,860 in
Medicare outlier payments were covered over fourteen outpatient procedure claims for the
insertion of devices. It can be determined that Medicare accurately paid eight out of the fourteen
claims processed by WPS. The remaining inaccurate paid claims were due to hospitals
overstating the number of devices or units inserted during outpatient procedures. This resulted in
unwarranted outlier payments, totaling WPS's overpayment of $17,996. The FISS failed to
adequately prevent and detect incorrect payments (Department of Health and Human Services,
Office of Inspector General, 2012, p. I).
As an executive for the WPS Insurance Corporation, a proposal to the board of directors
is given in response to the office of inspector general. It is advised that CMS prepare more robust
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and detailed plans to monitor unit amounts for medical equipment better and to improve FISS
prepayment changes. In addition, it is recommended that the OPPS offers programmers
additional assistance when learning coding techniques and methods for devices and units to
improve accuracy. Preventing inaccurate payments is possible by implementing a contingency
plan to improve documentation. It is critical to adequately document a procedure, such as the
materials and methods used. This documentation ensures that the appropriate procedures and
treatments are executed.
In addition to contingency plans and documentation, consultation can avoid incorrect
payments. Improving the consultation between surgeons and nurses is beneficial to identify
available materials accurately. Consulting with a billing specialist ensures the use of accurate
billing codes. Third-party audit companies may be hired to analyze documents and determine
where errors occur, preventing them. Additionally, having regularly scheduled meetings with
billing staff, surgeons, and nurses to discuss procedures and equipment is beneficial. Lastly,
ensuring software receives updates to stay current and complete is necessary.
With CMS, WPS could improve processes by tightening control to guarantee the accurate
fitting and number of medical devices used. Through the collaboration of CMS and WPS,
hospital processes could be improved through better control and accurate filing of the number of
devices used in a procedure. A lack of communication results in a lack of awareness for needs
such as categorizing claims and medical equipment units on hand, leading to improperly
categorized outpatient claims and insufficient resources. Under panel responsibility, they must
confirm and guarantee party agreement and maintenance to ensure satisfactory medical
processes. Doing this reduces misdiagnosis and underpayments and increases patient health
overall. CMS can improve WPS's understanding by providing thorough information on what is
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being offered and delivered and providing adequate training to improve methods. The thorough
explanation of available services and equipment by WPS should be improved, requiring CMS
calculations to provide a detailed explanation of its expenditures.
These situations differ depending on commercial payers and Medicare involvement.
Commonly, to safeguard financial interests, commercial insurance firms must avoid insuring
persons who will require medical treatment. Commercial payer adoption increases cost charges
from Medicare Fee-For-Service (FFS), and Medicare Advantage plans (Dinerstein, 2022). If a
commercial payer is involved, Medicare fee-for-service and Medicare Advantage plans increase
costs. While typically commercial insurance is priced higher than Medicare and its Advantage
plans, the pricing to see a physician in office by patients who are established has similar pricing
to commercial payers and Medicare plans. The insurance industry's structure makes it difficult to
use commercial insurers to protect vulnerable individuals, requiring expensive treatment because
commercial insurance companies are profit-driven and aim to minimize risk. In retrospect,
Medicare is designed to provide healthcare coverage to the elderly and specific individuals with
disabilities. Reimbursement rates are set because commercial payers charge higher pricing than
Medicare, except for basic services such as office visits. Service availability also differs between
commercial payers and Medicare due to factors such as network agreements and coverage
policies (Maan & Striar, 2022).
Conclusion
It is essential to report devices used and related charges accurately. Failing to do so
results in inaccurate outlier payments. Several steps can be taken, such as preparing thorough
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plans to improve the monitoring of devices and implementing contingency plans, with quarterly
reviews to analyze their effectiveness continuously. Collaboration and communication between
providers and nurses are critical to a clear understanding of categorizing claims, medical
equipment units on hand, and expenditures. Prioritizing communication improvement results in
benefits such as properly categorized outpatient claims and sufficient resources. WPS must have
a clear understanding and adequate training to understand what devices are offered, delivered,
and available. Party agreement and maintenance of these methods will ultimately lead to correct
payments and improved patient health.
Chapter 5 Adverse Events in Skilled Nursing Facilities (Case Study Two)
A series of studies were conducted over several years (2008–2012) to evaluate harm
resulting from medical care, which will be referred to as an "adverse event." These studies
include a congressionally mandated study determining a national incidence rate for hospital
adverse events. Methods were developed to identify these events, determine which were and are
preventable, and measure how much these events cost Medicare programs. Through evaluation,
the study shows that skilled nursing facilities (SNF) post-acute care intends to aid beneficiaries
in improving health and function following hospitalization and is second to hospital care among
inpatient costs to Medicare. Patient safety is often more prioritized and less attended to over
resident safety in SNF. The study was conducted by estimating the national incident rate,
preventability, and cost of adverse events in SNF through a medical record review consisting of
two stages to identify events for a sample group of 653 individuals. The individuals in this
evaluation must be Medicare beneficiaries discharged from hospitals into post-acute care (SNF),
with SNF stays of 35 days or less.
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It can be determined that 22% of Medicare beneficiaries experienced adverse events
during their SNF stays, and an additional 11% of Medicare beneficiaries experienced temporary
harm events. Physical review determination shows that 59% of the reported adverse events were
preventable and can be linked to inadequate care, monitoring, and failure or delay of needed
care. Over 50% of residents who experienced harm sought hospital treatment, equating to a cost
of $2.8 billion in treatment for Medicare caused by SNFs in a fiscal year (Moore, 2014). CMS
has safety standards requiring qualified health plan issuers to verify that facilities meet patient
quality and safety requirements and ensure programs and partnerships are in place to promote
effective interventions like reducing patient harm and risks and improving provider coordination,
monitoring, and performance. These standards promote patient safety interventions while
improving healthcare quality and reducing harm (CMS, 2023). Adequate involvement of CMS is
essential.
A series of research on adverse events over several years determined that the adverse
events were due to medical treatment. As a result of these findings, CMS is expected to
determine that SNFS does several necessary tasks to reduce these errors significantly and
effectively. The first step is ensuring that all safety laws and standards are being followed. Staff
must stay vigilant when caring for these vulnerable individuals to avoid resident injuries and
dangers. To minimize harm, CMS's involvement in organizing activities and techniques
pertaining to these care facilities will aid Staff and enhance patient safety practices. Safety
practices may be frequently evaluated to determine their effectiveness and if alteration is
necessary. Any new methods or tools to evaluate adverse events must be made accessible by
CMS to these facilities to offer support to these facilities. Lastly, offering initiatives to improve
the function of patient care and prevent adverse events may be beneficial.
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Conclusion
Skilled nursing facilities and post-acute care are Medicare's second-highest inpatient costs. These
facilities intend to aid beneficiaries with after-hospitalization health and functions, but resident
safety is often not adequately prioritized. Study findings show that following safety laws and
standards and improving CMS involvement in organizational activities, initiatives, and quarterly
reviews greatly support these facilities. Following these guidelines will improve their function,
ultimately positively affecting patient care and the number of adverse events.
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References
CMS. (2023).
Patient Safety
. CMS.gov.
https://www.cms.gov/medicare/quality-initiatives-
patient-assessment-instruments/qualityinitiativesgeninfo/aca-mqi/patient-safety/mqi-
patient-safety
Dinerstein, C. (2022).
Rand Corporation Reports Commercial Insurers Pay More for Healthcare
—the American Council on Science and Health.
Maan, C., & Striar, A. (2022).
How Differences in Medicaid, Medicare, and Commercial Health
Insurance Payment Rates Impact Access, Health Equity, and Cost
. The Commonwealth
Fund.
https://www.commonwealthfund.org/2022/how-differences-medicaid-medicare-and-commercial-
health-insurance-payment-rates-impact
Moore, J. (2014).
Adverse Events in Skilled Nursing Facilities: National Incidence Among
Medicare Beneficiaries
. U.S Dept of Health and Human Services, Office of Inspector
General.
https://oig.hhs.gov/oei/reports/oei-06-11-00370.asp
United States Department of Health and Human Services. (2012).
Review of Outpatient Claims
Processed by Wisconsin Physicians Service That Included Procedures for the Insertion of
Multiple Units of the Same Type of Medical Device in Calendar Years 2008 and 2009.
http://oig.hhs.gov/oas/reports/region1/11100532.pdf