The Medicaid Eligibility Quality Control

There are always key elements to assessments and reviews, including the family and friends. Everyone has a responsibility to support individuals and bearing in mind ‘need to know’ information. The aim being able to achieve the highest goal to maintain effective open channels for everyone.

Internal Processes * Qualify for a Patient Centered Medical Home (PCMH) * Communications – (entire staff) – with a quarterly staff meeting * Improve comfort levels with ICD-10 diagnosis coding

Regular reviews, target setting and referring to the initial assessments target setting is vital in ensuring a

The continue use of ICD-9 codes after the effective date could result in the denial of reimbursement claims. This task can be assigned to the healthcare organization’s management team to determine a solution avoiding a break down in the system. Rahmathulla states, “In instances of an audit, appropriate documentation will make the query process substantially easier while enabling coders to clarify issues without having to query the provider multiple times for answers” (“Migration To The ICD-10 Coding System S187). It is important to accurately document to reduce the amount of claim denials. With the new specificity requirement of the ICD-10 and documentation supporting a claim, lowers the chances of healthcare fraud. The healthcare management team will oversee the process to prevent the risk of exposure.

In the state of Texas Medicaid is funded by state and federal programs. Those eligible to receive Medicare benefit is the low income individuals, families, children, pregnant women, elderly and individuals who suffer with disabilities (Hegar). The Texas Health and Human Service commission (HHSC) distributes the Medicaid (Hegar). Those receiving Medicaid benefits in the fiscal year of 2010 were found to be 55 percent female and 77 percent under the age of 21 (Hegar). Children accounted for 66 percent of all Texas Medicaid recipients in that year; however, 32 percent of those children actually received health care (Hegar).

Following the death of a Medicaid recipient, the program not only can but must attempt to recover costs from the estate of the deceased. Medicaid's official site says:

People don’t like being sick, however, some Missourians forego preventive care, required doctor visits and beneficial medicines because they cannot afford them. They may be working in part time jobs, seasonal jobs or other unskilled labor jobs and lack affordable health insurance. They are the poor people below the 138% federal poverty level (FDP). According to Chris Kelly, a former Representative of the Missouri House for district 24, the West Plains hospital Ozark Medical Center’s (OMC) service area includes more than 9,000 uninsured adults (p1). So, what do you do when you are poor and sick and can’t afford a doctor’s visit? You go to the emergency room of a local hospital and the hospital absorbs that

Affordable Care Act requires that all skilled nursing care centers develop Quality Assurance and Performance Improvement programs. The statute requires the Centers for Medicare & Medicaid Services (CMS) to develop a prototype QAPI program, establish standards, and provide technical assistance to centers on the development of best practices in order to meet such standards.

The Centers for Medicare and Medicaid Services support quality initiatives. The mission of CMS is quality health care for people with Medicare which is a high priority for the president. CMS began to start quality initiatives back in 2001 to assure quality care for all Americans through accountability. There are various quality initiatives that focus on every aspect of the health care system. From focusing on reporting quality measures for nursing homes to kidney dialysis facilities. Consumers can use the information provided on their website for these health care settings to assist them in making the right choices for the care provided.

b) Facilitating the reviews performed by supervisors, managers, engagement partners, engagement quality reviewers, and PCAOB inspectors.

Part A (Hospital Insurance program) covers inpatient hospital stays, home health service, and skilled nursing facility. In addition to this, Medicare pays for 100 days of care in Medicare-certified skilled nursing facilities as well as for the patients staying in Medicare certified hospice. Some people do not pay any premium for part A due to the taxes paid by them or their spouse during their working years. Moreover, contribution comes to Medicare through payroll taxes paid by individuals which make them eligible for the benefits. In order to become eligible for this premium free Part A program, individuals or their spouse must have forty credits after working at least 10 years. However, people, who do not have forty credits, will pay a monthly

This Project Charter describes the purpose, scope, objectives, estimated cost/ effort/ duration, risk and constraints, assumptions, approach and organization.

April, 24, 2015 – conducted training on the SOP with 9130 reviewers in the National Office.

The MCCQE Part II is an Objective-Structured Clinical Examination (OSCE) which assesses the knowledge, skills and attitudes essential for medical licensure in Canada. It is comprised of a series of clinical stations at which candidates are expected to interact with a Standardized Patient in the same manner as they would they interact with actual patients while being observed by a Physician Examiner. Although the examination is approximately 3 hours long, candidates should plan to be at the examination site for a minimum of 51/2 to 6 hours.

The two types of review processes that the RAC program utilizes are the automated review and the complex review. The automated review requires no medical record; errors found during the automated review must be clearly noncovered services or incorrect application of coding rules and must be supported by Medicare policy, or approved by coding guidance.(Georgia Physician) The complex review requires a medical record, and may require a physician to submit medical documentation. In addition, records requiring a complex review are those with high probability of noncovered service or when on definitive Medicare policy, Medicare article, or Medicare sanctioned coding guideline exists.(Georgia Physician) RAC audits can review all aspects of the medical record including but not limited evaluation and management (E/M) services as related to those that should be reimbursed as a component of a global surgery package, as well as those on duplicate claims. By CMS regulations RACs are generally permitted to