South Carolina Heart Center Billing Case Study

There are 6 key steps for a successful medical billing process which are checking in patients for their appointments. When you are checking patients in you will make sure the patient demographics is updated and correct. The second step would be checking the eligibility and verification for insurances. You will verify patients insurance because a change in a patients insurance could impact benefits and authorization information. The third step would be completing medical coding of diagnosis, procedures and modifiers. When completing this step you will need to make sur you are using the correct diagnosis codes to describe patient’s symptoms and illness, use the accurate CPT and HCPCS codes modifiers to provide additional information about the service and procedure performed. The insurance payer could only make an accurate assessment if they have they correct codes and modifiers. The fourth step would be the charged entry which refers to entering in the charges of the services that were received. The fifth step would be claims submission which means once the claim have been properly completed it should be submitted to the insurance company for payment. The final step in this process would be payment posting which involves posting and deposit

Id. In order for providers to avoid costly claim denials, a risk management and compliance program should be in place and annual monitoring and auditing of internal controls needs to occur on a regular basis. This text will review the issues that medical providers face with coding and billing regulations, the consequences of improper billing and coding, and resolutions that will aid in the prevention of claims being denied.

"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.

The role of the Medical Insurance Specialist is very important to the financial operation of a doctor practice, hospital or other medical facility. A Medical Insurance Specialist collects all the information necessary to prepare insurance claims, enter patient demographics and insurance information, enter ICD codes and CPT billing codes, research, correct and resubmit rejected and denied claims, bill patients and answer patient questions regarding charges. The billing process is actually the process of communication between the insurance specialist, medical provider, patient and the insurance company. This is considered the billing cycle. The billing cycle could takes days to complete or it could take months.

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

Health care organizations generally volunteer to seek accreditations from the Joint Commission by allowing expert surveyors evaluate their facility. The surveyors are made up of a multi-disciplinary team that spends an average of two days inspecting health care facilities. The purpose for the inspection is to evaluate a health care facilities standards, staff, regulations, policies and procedures, and quality improvement, and performance measurement. The Joint Commission surveyors generally look to see if the organizations governing board is taking part in ensuring that the facilities has facilitated safety and quality assurance program.

Claim submission processes are claims that are submitted online, and payments are processed electronically after a visit to the doctor office the physician send out a bill to the insurance claims processing center all information that is relevant the intake forms and the patient appointment sheet as well as the proper services documentation. Which is evaluated to see if it covers the services if the services are covered by the insurance company a payment is then submitted for the balance that is remained if not insured the person is reliable for the balance that is left over as well as the co-payment.

As the industry continues to move away from some of the Medicare programs that were created during the Obama presidency,  the Centers for Medicare & Medicaid Services (CMS) is also pulling away from specific value-based initiatives, such as mandatory bundled payments. The CMS officially canceled two of the models that were included in the Bundled Payments for Care Improvement (BPCI) Initiative.

The South Carolina Title XIX State Plan, also known as Medicaid, was designed to maintain the provision of “quality health care to low income, disabled, and elderly individuals” (South Carolina Department of Health and Human Services, 2016). The South Carolina Department of Health and Human Services (SCDHHS) acts as the designee for this administration, managing the state and federal reimbursement of funds for approved medical providers. Services are designed to provide services for diagnosis, treatment, and management of illnesses. The Management Care Organization program provides insurance coverage through a network comprised of contracted, providers who are paid a “per member per month capitated rate” (SCDHHS, 2016). These

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.

In Michigan, the Office of the Inspector General (OIG) was created in 1972 by the Michigan Department of Health and Human Services to help maintain accountability in efficient and appropriate administration of HHS programs (OIG, 2013). The OIG investigates alleged fraud in these programs as well as reviewing policies and procedures and recommending improvements in ways to counteract and detect fraud. In addition, OIG monitors compliance with reimbursement regulations. OIG provides guidance documents for compliance programs for various types of providers to use to develop compliance programs in their facilities. The compliance plans include development of policies, including those for accurate coding, internal monitoring and auditing, naming of a compliance officer, and appropriate training (Peden, 2012).