A third common coding and billing error is billing for non-covered services or billing over-limit services. The insurance specialists need to make sure he or she is billing for services that are covered and also needs to make sure they are not billing for over-limit services. The effect the Medicare National Correct Coding Initiative has on the billing and coding process is that it controls improper coding that leads to inappropriate payment for Medicare claims. CCI had coding policies that are based on coding conventions in CPT, Medicare nation and local coverage and payment policies, national medical societies’ coding guidelines, and Medicare’s analysis of standard medical and surgical practice (Valerius, Bayes, Newby, & Seggern, 2008). CCI also offers edits, which are used by computers in the Medicare system to check claims.
This type of practicing cannot continue, patients could become ineligible and dropped from their insurance, the hospital can suffer lawsuits for falsifying document and falsely charging patients and insurance. If I was put in this situation and came across this. I would do some informal peer monitoring further into current, past patient records and procedures to clarify if their medical issue matches up with the surgical procedure Dr. Gottrocks listed. Once I have the evidence, I would write a formal complaint to the hospitals compliance office and
If an incorrect procedure is sent for billing, the result could be a physician being delayed a payment, or, missing out on payment altogether. If a claim does happen to be rejected, it must be sent back to where it originated for readjustment, and resubmission to the insurance provider. The end results in these situations could affect the accounts receivable portion on the physicians end, and money owed by a patient may end up in collections. One of the biggest downfalls to situations regarding improper and/or incorrect coding is the loss of revenue. The end result for any one mistake could cost into the thousands of dollars.
I would suggest the following: Training for all data entry employees and their emendate managers. The training should cover how to enter data correctly but also the importance of accurate entry. The goal of this training should be to tie in the effects of inaccurate data to the loss of an employment due to lack of federal funding. I would also suggest an electronic tracking program that follows the inputs of every employee, which would allow the managers to follow the data entry to the employee who entered it. This program would be an incentive based program to allow managers a way to track which employees has accurate entry and which employee might need more training.
The VA Hospital Systems Method to Improve Patient Safety: Electronic and Personal Health Record Anthony Bucki, MSN, RN Governors State University MIS 7101 INTRODUCTION It is well-known that safety is jeopardized when complete medical information is not available to all clinicians treating the same patient: incompatible treatments and medications can cause catastrophic results, expensive test results can be lost, and critical time can be wasted incorrectly diagnosing health conditions (Fischman, 2005). This lack of an electronic personal health record poses increased hazards to patients, particularly those who have multiple health conditions and numerous care providers. For individuals juggling chronic conditions, it can become a full-time
Pelvic inflammatory disease (PID) may be difficult to diagnose. A health care provider may order tests to identify the infection-causing organism (e.g., chlamydial or gonorrheal infection) or a pelvic ultrasound is a helpful procedure for diagnosing PID. After observing diagnostic test results the health care provider will determine and prescribe the best therapy. PID can be cured with several types of antibiotics. “Samples of the bacteria from the upper genital tract are difficult to obtain and because many different organisms may be responsible for PID” (Stoppler 2012).
This can be wrongful diagnosis, being given the wrong medication, or having their private information not properly protected. A few more examples would be receiving/giving improper treatment or care sometimes causing death. Upon any of these events taking place the wronged party will produce a lawsuit against the medical company or even just the professional. Medical malpractice statistics have sky rocketed ever since the healthcare system became more informal and mechanical. (McDonald, Chad, Hernandez, Marlow, Gofman, Yana, Suchecki, Shawna, Schrier and Wayne 2011) stated that “The most common factors leading to medical errors included failure to obtain a proper medical history, order the appropriate
Week 4 IHMO Assignment Davina Hall Medical Basics and the Healthcare Claims Cycle Ms. Blair UMA Three reasons a claim can be returned by the carriers could be Incomplete, Invalid or Rejected. Incomplete claims are claims that are missing required information. Any Medicare claim missing necessary information; such claims are identified to the provider so they may be resubmitted. A claim may be sent back because it is rejected; when claims need investigation and answers to some questions. A rejected claim is also an insurance claim submitted to an insurance carrier that is discarded by the system because of a technical error (omission or erroneous information) or because it does not follow Medicare instructions.
This is an important aspect for physicians to understand because medical misconduct may prove to be detrimental to their career. Identifying the civil complaint process for patients or consumers used in the event of suspected professional misconduct or incompetence provides a clear understanding of how the consumer files a complaint of a physician. Explaining the role of the respective regulatory agency in investigation of allegations, determining, and applying any appropriate disciplinary action present an explanation of how misconducts are held accountable in the health care industry. Identification of potential criminal liabilities for physicians related to abuses perpetrated in practices involving these issues as well as misconduct emphasize why physicians must treat patients adequately in the proper manner. The appropriate risk management strategies and quality assurance programs that offer in reducing the risk of liability and negligence are of value to many organizations.