Evaluating Compliance Strategies

"Medical coding professionals provide a key step in the medical billing process. Every time a patient receives professional health care in a physician’s office, hospital outpatient facility or ambulatory surgical center (ASC), the provider must document the services provided. The medical coder will abstract the information from the documentation, assign the appropriate codes, and create a claim to be paid, whether by a commercial payer, the patient, or CMS." (Aapccom, 2015) It is very important that billing coders have a full understanding of how to properly use medical codes to prevent denial of claims submitted.

H. (04/2015). Comprehensive Health Insurance: Billing, Coding & Reimbursement, VitalSource for Allen School of Health Sciences, 1st Edition. [Bookshelf Online]. Retrieved from https://online.vitalsource.com/#/books/9781323131503/

Job descriptions, procedure manuals, and office handbooks are critical to the success of a medical office because they

The E/M code's is a big important part in this process. Being a health care professional, using the medical code's. like medicare, medicaid, other private insurance to be reimbursement. If not using the right code, the doctor office, hospital, and urgent care. Will lose a lot of money. So using the right cpt code's insurance companies, office, hospital, and urgent care can be reimbursement correct. Cause CPT code's are formed with 5 digits.

The purpose of this assignment is to review the factual content of and critically reflect upon the legal compliance considerations of eight major areas including, the Joint Commission, HIPAA/HITECH, Health Finances, Revenue Cycles, Medicare Recovery Audit Contractors, OIG work plan, OIG Corporate Integrity Agreement (CIA), the False Claims Act, and compliance and Provider Self Disclosure Protocol. These key elements have been provided by the GRC software Compliance 360 webpage.

Some estimate that the federal government loses 30 percent of every dollar it spends on medical claims, due to medical billing mistakes and fraud. With so many loopholes and regulations surrounding Medicare, it is impossible for one person to know every nuance. However, constant diligence and ethical practices are a cornerstone of catching and preventing medical billing mistakes.

As enforcement activities increase by the Department of Justice, though the above report of fraud and abuse was intentionally carried out over a seven-year period, it becomes clearer every day that even an unintentional billing mistake can lead to charges of fraudulent billing with severe penalties. In the end, the risks of not having an update to date and strong compliance program can potentially result in the damage financially to the specialty physicians practice and reputation can be substantial. It also requires

Imagine the following scenario: Mr. Jones, a patient of Dr. Brown’s arrives for his annual wellness exam. Mr. Jones feels great, with no complaints. When he sees Dr. Brown, Dr. Brown spends 15 minutes reviewing his last office note. He listens to Mr. Jones’ heart and lungs, checks his ears, eyes, nose, and throat, palpates his abdomen, and looks at his extremities for swelling. Everything looks fine. Reimbursement for annual wellness visit has a typically billable value of 50 dollars. However, Dr. Brown documents Mr. Jones office visit as an extended visit, not an annual wellness; that visit now billable value of more than 100 dollars. The medical coder submits the bill as documented. This is up coding.

Jeff has over 20 years in the compliance field. As a former Deputy United States Marshal and Special Agent, he has conducted healthcare investigations regarding a myriad of providers and payors. Jeff has testified in federal courts and state superior courts as well as numerous regulatory proceedings. Jeff possesses a great deal of experience in the design and implementation of compliance and HIPAA programs.

For my process report, I have chosen the topic of the CMS-1500 health insurance claim form. In the medical insurance field, the current popular form of billing is the use of the 837P (Professional) format, which transmits health care claims electronically.

The goal of adopting the lean system by our health care organization was driven by obtaining the GCI accreditation and becoming one of the lead healthcare organizations in the middle east. At the beginning It was difficult to fully implement that system by a highly hierarchical organization. Until now we have consistent modifications in order to transit from a partial lean approach to a larger scale ( Graban, 2011). One of the most challenging issues in PICU sitting was regarding chronic patients who required long term ventilation. The hospital administration received numerous complaints from the admission office, ER manger, PICU manger and nursing staffs. The bed occupancy of the PICU reduced, which in turn lead to increase the waiting time

Operating a medical group practice is a massive undertaking for administrators which causes them to face numerous challenges. Two external obstacles that they face are (1) reimbursement and (2) governmental and regulatory issues. Compensation is a contentious issue because although the cost of healthcare service is going up the amount of revenue that the organization receives is declining. As for governmental and regulatory matters such as HIPPA, this can create barriers in regards to billing and the delivery of care. One way to overcome the reimbursement matter is to having a competent billing staff that is up to date on the rules to ensure that when a claim is submitted its done correctly so that the practice can obtain the maximum payment

As Democratic and Republican leaders call on Democratic Rep. John Conyers to resign in the face of multiple allegations of sexual harassment, including one that led to a settlement, the office set up by Congress to handle sexual harassment and other workplace complaints says that it is barred by law from even acknowledging that settlement or where it came from.

Combat compliance is framed as an analytic puzzle related to the variability of behavior, or responses of combatants, both individuals and as a collective, to the realities and risks of warfare. The underlying assumption here is that there is an intrinsic risk of death in any scenario of combat (Magagna, 2016). The enemy is always rationally assumed to have an interest in your death. What follows is that obeying of commands presents itself as an implicit acceptance of such risks. The puzzle here is figuring out how and why vastly differing reactions occur. At some points soldiers show limited levels of compliance, sometimes even ending up in mutiny, while in other cases units show extremely high levels of compliance, exhibiting tenacity under conditions of overwhelming odds (Magagna, 2016). This essay attempts to explain the factors that give rise to the variability of combat compliance. What is important, as alluded to earlier, is to be able to provide a generalizable argument that is applicable across time and space. The essay will first lay out of varying levels of combat compliance to discuss the characteristics and consequences of variability. Secondly, it will explore and contrast the factors of automaticity as a function of training and institutional design and the factor of the combat contract as a rational cost benefit analysis of material and moral incentives, in an attempt to critically analyze their merits in accounting for the variability of combat compliance.

Shared governance is important to compliance in order to keep all staff accountable for compliance measures. Shared governance is an organizational model that gives all management and staff control over their actions and practices and extends the influence of administrative areas (Hess, 2004). Giving all managers a voice can help improve governance compliance and operations by promoting teamwork and accountability among staff throughout the entire organization.