HIM310 case study 3 and 5 final

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Health Science

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Dec 6, 2023

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1 Case Study Three and Five- Claims Processing & Adverse Events in Skilled Nursing Facilities Ashton Henwood HIM310: Healthcare Reimbursement Instructor: Crystal Sayler November 20, 2023

2 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

3 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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