C806 Performance Assessment Task 3

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C806 Pharmacology Performance Assessment Task 3 Lindsay McGahee C806: Pharmacology Kristin Minter July 13, 2023

A1. Financial Impact The financial impact of a scenario like this can be significant for a hospital. In this scenario, at least $6,900 was lost on each rejected claim. There were at least six other occurrences of this same issue. Including the one described in this scenario, the hospital lost at least $48,300. This is a significant amount of money to continue to lose over a documentation error. A2. Issues When a documentation error is made such as the one described in this scenario, it can cause quality-of- care and legal issues in the future. If there is a documentation error made, the patient’s medical history will show the incorrect infusion. This can lead to issues in the future with treatment decisions, prescriptions, and repeat treatments. If other providers believe the patient had a blood transfusion instead of a blinatumomab infusion, this can also cause a legal issue if the patient chooses to sue over incorrect treatment due to a documentation error. A3. Corrective Action Plan A corrective action plan could implement a new dropdown system in the medication reconciliation section of the EHR to classify the choices by type or category instead of alphabetically. Another option could be to use the NDC number to input drug information rather than the name. B1. National Drug Code In the scenario provided, the use of National Drug Codes (NDCs) could be used to eliminate these errors. If the NDC code was used instead of selecting the drug alphabetically, this could prevent an issue causing financial, care, and legal issues for the hospital and providers involved. NDC codes also provide more security with patient information through HIPAA as they list the NDC number rather than the name of the drug. (Oachs & Watters, 2020, p. 155-156)

B2. Fraud and Abuse To report suspected fraud and abuse in collected data, an HIM professional would need to gather as much information as safely possible to include in a report to the Office of the Inspector General. This information can include the name and contact information of the individual related to the complaint, the timeline of events explaining the scenario that the suspected activity took place, the name(s) and contact information of any other witnesses to the suspected activity, and any supporting evidence to the claims. (HHS.gov, n.d.) B3. Internal Audit An internal pharmacy audit is important in this scenario because it would likely bring the repetitive incorrect data entry to light and allow the pharmacy to implement a better system to avoid this issue in the future. It is also important so the pharmacy can potentially rebill corrected claims in a timely manner to relieve some of the financial burden caused by this mistake. B4. Points to Consider in Audit There are three important points to consider when conducting a pharmacy revenue cycle internal audit. The first factor to consider when auditing a claim is the modeling or insurance assignment. If the claim was submitted to the incorrect insurance provider, that could be a reason for denial. The second factor to consider is the fee schedules or contractual rates for each payer. It is important to determine if the payment received matches the agreed upon pricing in the contract. The third factor to consider is the quality of charting and coding. If there is an error in the patient’s documentation or the claim that is sent to the insurance company, this could also be a reason for denial or overpayment/underpayment of the claim. (Oachs & Watters, 2020, p. 265)

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