Escalation Case Study

Customers must use the internet to fill out an online form to address their complaints or service needs. These forms are processed by employees in your department. Currently the turnaround time on any given form is between four to eight hours. This creates a number of other customer complaints. Project Call Center is designed to reduce this turnaround time by 75% by creating and staffing a call center in Tampa. Building acquisition, building renovations, building fit out, IT system upgrades, and hiring and training of staff are estimated to cost $8.5 million dollars. This $8.5 million dollars can be paid evenly in any two quarters in the next year. In addition, seven new employees will need to be hired at $40,000 burdened labor costs per year to staff the call center. Management of this project could easily be done with the current in-house staff. Most of the work of this project would be outsourced and will have minimal impact on day-to-operations.

The carrier has denied coverage of BHRS as requested as not medically necessary. There is a letter from the carrier to Melanie Smith dated 02/18/16. In the letter, the carrier states in part: “Based on review of all information provided, the second level grievance review committee has decided that the decision of the first level grievance review committee is upheld.

assignment within 48 hours. This includes cancellation due to inclement weather and company or deaf client cancellations.

SC received a telephone call on 10/16/2015 stared 9:34 and end at 9:41 am from Tricia Crooks at Liberty Resources Home Choices (LRHC) Community Outreach and Enrollment Leader. Stating that she spoke Pa and he wants to resume his service order with LRHC for PAS service. SC informed SC that this information will first need to verify with Pa. SC expressed concerns about LRHC being able to fulfill service since they had the case unstaffed for over two weeks (09/25/15-10/15/2015). Tricia apologized on behalf of LRHC, and stated that they have someone assigned and is ready to go all is needed is the resumed service order ASAP. SC again explained to Tricia that Pa has to confirm this besides Pa was very adamant about switching provider because the

RE: E/M codes 8/5/2015 4:37:46 PM Definitely using the correct E/M code's. Document the code's for reimbursement for medicare, medicaid, or private insurance. Not done correct big lose of money. You make a great point on this one

In your email you mentioned waiting until November to be able to get a Service Extension on our V7R1M0 software. That will probably be a new quote and if it can be for more than one year that would be ideal for us.

review the SFL audit report and here is the numbers of patient accounts that we can't bill out to the SFL program b/c the patient don't qualify or never complete the SFL application. Please review my founding and let me know How do you want me handle all this claims. My suggestion is if the patient is active with Title X we can adjusted off under the Title X program and just bill the patient for the Title X copay fee and the lab fee if the patient is scale level is B,C,D,E & F. I will be waiting for the final decision that you and Sara will like to make.

The medical form was not totally in compliance with the “Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), even though the claimant had a written notice there was no effort put forth in order to secure an approved medical authorization and

The patient is very independent in his home and is able to perform all ADLS within the home without any addtional assistance. MSW asked patient if he was interested in any addtional care giving support in the home, but patient declined addtional support at this time. Patinet stated he gets transportation from his neiabors to the store when needed. MSW offered the patient additional transportation services, but the patient declined needing any addtional transportation services at this time.Patient reported falling back in 2004 off the steps and was air lifted to the hospital. Patient reports having diffculty paying doctors and helicoter bills. Patinet's only income is through SS for $847. Patient reported that was the only time he was fallen in his life. Patinet has only been in the hospital two times during his lifetime. MSW offered life alert services, but the patient was not interested. Patient stated his only concern was being able to afford his doctor and helicotor transportion bills. MSW connected AHCCCS and spoke to represtative regarding getting patient signed up for the medicare savings program. Representative stated the patient has already applied for AHCCCS back in

Just looking at this claim form can be a bit intimidating if you have never dealt with them before. But if you were to take a moment to glance over the form and get a feel for what information is pertinent and needed to complete this claim form. This form to me is one of the easiest claim forms that will have to filled out and submitted in the medical office setting. Upon the first time filing this claim form it is important to have all the correct and updated information from the patient, and that the physician or hospital has included all the correct codes and the correct information to be able to file this claim. As with any claim, without the correct information and correct, the claim could be rejected and denied for reimbursement. That not only will delay the payment for services rendered, but will always add more to the medical office administrator work load. With a rejected claim, the medical office administrator will have to go over that claim form again to find the errors and then resubmit the claim. Having to do this, on top of the work load he or she may already have could put them behind on the daily duties already on the

SC received VM form Tanya, ERS provider via Active Aid Solution. Tanya reported that they received a monthly maintenance service order for ERS but did not get one for the installation and requested that SC put it in ASAP. SC created service order in Oracle and completed service order in SAMS. SC reviewed Pa care plan and everything else looks good. SC placed phone call the Penn Asian Senior Services enhanced day care provider. SC call was transferred to Soon Pack Pa’s social worker at the center. When Soon got on the phone SC introduce self and stated reason for calling (was to visit Pa at the day center) Soon stated that, that would be ok because SC must be there before Pa’s leaves at 1:45 PM. SC asked why Pa leaves so early and Soon reported that, that’s

Would you please correct the patient sliding fee scale information that being entered incorrectly under the patient policies tab. I review the patient household family income ($22,432.41 for 3 family members) and the sliding fee scale level is B and under the patient policies tab the Sliding fee scale was selected as a Scale A and this is incorrect . You FWD message to the billing pool and PMG FWD back to the billing department b/c the information don't match. Please do the appropriate corrections and email me back so I can advise PMG.

Ms ROBERTS, DESIRE M, Case GB9071, expressed her concerns regarding an unmet copay from September of 2014. Her case has not been resolved yet. She said that she went to the SSP, Albany Branch to apply for ERDC, but she was told would not qualify for ERDC due to unmet copay. She said her husband and she are working and need ERDC. Ms Roberts stated that she has been sent back and forth between SSP, Albany Branch and DPU due to an unmet copay from September 2014.

This letter is in response to your first level Administrative Appeal filed with Horizon Behavioral Health on November 3, 2016. In this appeal, you requested reconsideration of the payment in the amount of $3632.16 on the claim for dates of service October 1, 2016 through October 4, 2016. You stated that the member was involuntarily admitted through the Emergency Department, therefore the claim should be covered at the full charge of $9137.40.

To meet the grant requirement of reporting your progress and project implementation within three months of receiving the grant, please submit the report by December 20, 2017. Please see attachment for more details.