Unit 5 Assignment
Jessica McNuer
HI215
Purdue Global University
After reviewing the case study my first recommendation would be to ensure that all Leave against
medical advice(LAMA’s) and discharge home claims are being coded correctly. The Department of
Health(DOH) overpaid $986,316 dollars for 74 of the 185 claims reviewed.
$904,525 of those dollars for
62 claims code indicated the beneficiaries where discharged home, but the medical records indicated
they where transferred to other PPS hospitals. $62,772 dollars for 9 claims were coded to indicate it was
LAMA but records show they where transferred. $6,151 dollars for 1 claim where the beneficiary was
transferred but between units within the same hospital. These should be checked more then once
before it is sent out.
Furthermore, I would recent training to ensure all staff is up to date with coding requirements, and
system requirements and procedures. This includes updating any systems used that could be out of date.
Ensuring the staff and systems are all up to date will decrease on the incorrect codes. This will also
ensure that all discharges will be coded correctly and funds properly allocated.
I also suggest working with other hospitals and DOH to create a fail proof system that catches these
errors before payment. This would help make sure that the code and payment match the medical
records. This system could either be computerized or a staff who have been trained to spot these issues.
Part 2
A.
Prospective Payment System or PPS
B.
Retrospective utilization review is a process that occurs after care is given.
C.
A payment arrangement for healthcare services in which a physician or group of physicians
receive a risk adjusted amount of money for each person attributed to them.
D.
Cost-plus reimbursements or retrospective reimbursements
E.
The principal diagnosis, up to 24 additional diagnoses, and up to 25 procedures performed
during the stay.
