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South Carolina Heart Center Billing Case Study

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The Billing department is responsible for claims denial management and rationales. A claim is a request for payment for services provided; in this case it would be for a physician office. The claim is submitted for reimbursement to the healthcare insurance plan by either the insured party or by the provider. South Carolina Heart Center billing department have a strategic development in the way they handle claims. Majority of insurance claims and checks arrive electronically. Then, the insurance claim enters task management feature within Group Practice Management System (GPMS) work queue basket and the software sort the claims by name. Several staff members within the department have specialty insurance claim areas that are assigned. One staff…show more content…
The officer have to go a website to register the facility’s physicians and tax identification number. After, registration the facility will start to receive audits electronically. The audit will declare that RAC have been reviewing a certain doctor usage of a CPT code and they want to receive a specific month or period of time of those records. The compliance officer looks for documentation the RAC auditor requested and prints it out. The process at SCHC is to send the request and log it in the RAC notebook. Recovery Auditor Contractor gives the facility a certain amount of time to respond to the audit. Medicaid and Medicare also conducts audits by randomly pulling paid claims usually retrospectively to make sure they are paying for the right procedure every quarter. If there was a charging error and the facility was overpaid by Medicare for a claim, the facility must resubmit the claim with the corrected CPT code and pay back the overpayment amount. Medicaid and Medicare also performs prospective audits this method is when the facility sent a claim to the insurance and they are not going to pay it without documentation. Typically, this means they are looking at something very specific that they think is incorrect. The billing department does their own internal prospective audit. The compliance officer audits the doctor’s CPT codes and staff to make sure codes were interpret correctly. The Joint Commission’s on-site survey process is the tracer methodology. The tracer methodology uses information from the organization to follow the experience of care, treatment or services for a number of patients through the organization’s entire health care delivery process (Facts about the Tracer Methodology, 2016). The system South Carolina Heart Center uses conduct tracer methodology is printing out arrive appointments and the router ticket
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