South Carolina Heart Center Billing Case Study

The Recovery Audit Programs (RAC) is to identify any Medicare collection that is under any detection and collection of overpayments that are made on claims of health care services that are provided by Medicare beneficiaries, and to identify any payments that are provided so that CMS can take any actions that can prevent future improper payments in all 50 states. RAC programs is a successful program that utilizes the recovery Audit to identify ant Medicare overpayments and underpayments to health care provider to suppliers in selected states. The demonstration that has been ran between 2005 and 2008 has resulted in over $900 million in overpayments that has been returned to the Medicare Trust Fund and there has been $38 million in underpayments that has been returned to the health care providers. This has resulted in Congress to require the Secretary of the Department of health and Human Services to have a permanent and national Recovery Audit programs to help on overpayments that are associated with services for which payment are made under Medicare part A or B Which is the Social Security Act. For every Recovery Audit has a responsibly to identify any overpayments and underpayments that is within ¼ of the country.

HIM Personnel play an important role in the Medicare system. Medicare has transitioned from “fee for service” to providing incentive payments for providers that issue high quality care at affordable prices. In order to achieve the “pay-for-quality” incentives hospitals and health care officials must improve their documentation processes. “If it isn’t documented, it wasn’t done” is more important than ever. It is the responsibility of the HIM professional to ensure the integrity of the patient chart. HIM professionals monitor the quality of documentation and ensure all clinical documentation is complete and accurate. HIM professionals are the key to identifying process problems while keeping in mind patient safety, quality of care, and revenue integrity. Medicare requires that hospitals report quality improvement measures in order to receive payments; HIM professionals can directly impact Medicare incentive payments. HIM professionals are directly involved with the Medicare Audit Improvement Act. The HIM professional collects health data that is subject to the audits; HIM professionals are the point of contact for responding to Medicare audit requests.

The state, where the provider is licensed, will send a representative in to survey clinical records and the practice for compliance with the COPs. Surveys are conducted every three to four years and as needed for any complaints posted against the provider. Clinical record audits, patient interviews, direct patient care, provider interviews are

from the doctor. The health information technician has to track down that doctor. Also, the Billing department may receive requests from unknown insurance companies. When this happens, the Billing department gets Medical Records to act on their behalf. The Medical Records then has to obtain an authorization form from the patient in order to fulfill the unknown insurance company needs.

The careful documentation and subsequent billing process within the course of a patient’s care is an important piece within the healthcare system as a whole. Proper documentation in a patient’s chart relating to any service or procedure is not only important for this patient’s future medical care, but for the facility to receive an accurate reimbursement for the services provided. Reimbursement is affected by every department within the hospital. Healthcare is a business in the long run, and inaccuracies within the reimbursement process will affect the financial stability of the hospital. If a department is mismanaging reimbursement data it could result

They review claims before Medicare pays the physician, and an analysis of claims after repayment. They identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of healthcare services. Every practice should be prepared to be audited at some point. The auditor basically goes around to see if any fraud is being committed. There are different kinds of audits such as Recovery Audit Contractor, Certified Error Rate Testing, and Probe Audits. Some things you can do to prepare your staff is avoid coding mistakes, accurately document patient charts, perform random mock audits, prepare implement policies and procedures, and review audited claims. I should also educate my staff the importance

Coding violations is one of common ways that health care providers can defraud the Government. Health care provider must enter a numerical “Procedure Code” CPT (Current Procedural Terminology) code or HCPCS (Health Care Common Procedure Coding System) code that matches the specific type of care provided to the patient in order to bill either a government health care program such as Medicare, or Medicaid or private insurance company such as Blue Cross Blue Shield or a for payment.

This can be done electronically or manually. While most claims are sent electronically now, some circumstances require paper claims and it is required for a medical coder to know both methods. The form used is called a CMS 1500 form. On this form you will input information provided by the patient during registration, add codes addressing charges for services, document primary and secondary insurance coverage, and include provider and practice data where the services took place. Normally, every claim is reviewed by the billing department several times for accuracy before it is

The Recovery Audit Contractor (RAC) program was created by the Medicare Modernization Act of 2003 and made permeant By the Tax Relief and Health Care Act of 2006. These private contractors are on consignment to identify and recover improper Medicare payments to healthcare providers. The American Hospital Association (AHA) feels the RAC audits are inaccurate, duplicative, increase hospital administrative burden, and are time consuming and costly to appeal. The AHA further asserts the RACs have no consequences to their poor performance.

The Florida Health Care Association is committed to bringing long term care emergency management planning to the forefront of our profession by aiding nursing homes in the development of effective emergency management plans which are comprehensive and aligned with state and local governments. FHCA’s Education and Development Foundation has partnered with the John A. Hartford Foundation, the University of South Florida, the Florida Department of Health and the American Health Care Association in the development of tools to support the emergency response system nationally, at the state and local levels, and at the nursing home.

South Carolina Heart Center is an outpatient based facility. The patients in the facility only flow in one cycle, meaning there is not a difference in the inpatient documentation or emergency department documentation. Responding to emergency situations is also the same as the route of transfer, besides the physician making a referral for a patient to another facility for continuity of care.

. Oversees the patient financial system, claim editor, and clearinghouse submissions in conjunction with IS/IT department to ensure accurate and timely claims submission, payment posting, collections, and follow-up.

You can comply with your obligations under Sections 6.7.3 and 6.12 in one of two ways. First, you can agree to a mutually-convenient time for the Hospital’s agents to conduct an on-site audit of Practice’s books and records, including books and records maintained by its billing service provider. Alternatively, you can produce the following documentation to the Hospital:

The case that I am reading about is about a woman who goes in for her year Pap smear slides wrong. The case took place at the Maine Medical Center. Since 2008 to 2011 when she went in for her yearly visit to her OBGYN she would complain of pain and even her doctor found something. The only way she got truly diagnosed, she had to go to another doctor and where they diagnosed her with stage 3 cancer. The new doctors that she went to believed that the cancer first appeared in 2008. Luckily treatment was started and she is now in remission.

The Leona M. and Harry B. Helmsley Charitable Trust continues to make notable investments in the health sector for improving the quality of care in the Midwest (Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming) through its Rural Healthcare Program. These initial investments pivot around the cardiac system of care and provide assistance to the emergency medical services (EMS) by equipping them with medical devices such as Automatic External Defibrillator’s (AED), mechanical CPR device LUCAS 2 and Simulation training support.