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 journal discusses how serious government views fraud and abuse in healthcare and. Fraud is health care settings is a serious crime; in 2010 U.S. attorneys were allocated approximately $2.9 million dollars in health care fraud and abuse compliance funding. These funds went to both civil and criminal health care fraud and abuse. One of the cases mentioned in this report was one of three hospitals settling allegations based upon excessive Medicare outlier payments. Our Lady of Lourdes Health Care Services Inc., the parent company of two hospitals in New Jersey Paid a $7.9 million settlement in December 2009.
In order to earn more money, HMOs use money to persuade doctors to deny necessary care to patients. Patients are the victim in this scenario. The government is not regulating insurance companies from exploiting the innocent. Manage care cater for terminally ill patient. Instead of increasing staff for the patient to receive adequate care , they use the same
Discuss the following a. Qui tam is known as whistleblower suits. In qui tam action a relator with personal knowledge of a fraud brings the suit against a defendant of behalf of the government. The knowledge with which the relator brings a qui tam action must be public knowledge but information that would not otherwise be available without the qui tam suit. b. HIPAA Privacy rule is the Health Insurance Portability and Accountability Act of 1996. HIPAA was enacted to improve the Medicare and Medicaid programs and the efficiency and effectiveness of the healthcare system by encouraging the development of a health information system through the establishment of standards and requirements for the electronics transmission of certain health information.
Security Breach Case There has been information regarding a breach in security, to the administration department at St. John’s Hospital, in regarding information on patients that is supposed to be secured or shredded. The current issue regards printouts in a restricted-access Information Service department, the problem is that the printouts are not being shredded as what the original policy had stated. The second problem is that the cleaning staff which comes in nightly have been observed viewing this information on more than one occasion. Personnel who currently work for the hospital observed these actions and brought it to the attention of the administration. This not only is against the policy and procedures set forth by the hospital but also is a HIPAA violation.
Using the ER for primary care is inappropriate states the president of the American Academy of Nurse Practitioners. The ER is obligated legally to treat all patients; health care providers eventually find ways to pass on the cost for treating the patients who are not insured to other patients such as to those who pay their medical expenses out of pocket. Technology is a major contributing fact to the growth of health care spending. Cutting fees will change a lot in health care spending but could be a negative on certain aspects and make all previous matters to be disregarded. Although a high value is often placed on the quality of nursing care, the skill of the physician, or the use of new medical technology, none of this matters much if the care is provided to the wrong person or at the wrong time.
* Medicare fraud occurs when medical institutions and health care providers collect reimbursement for services and medical care by fraud, including double billing, false coding, and intentionally charging for services that patients did not receive. Patients and employers are often
It breaks down the expectation of all the job duties and the expectations of the individual. Efficiency, accuracy, interpersonal skills, and attendance are important to having an effective department. When billing insurance companies a biller needs to be accurate to avoid denials from insurance companies. It can cause more work for the patient account follow-up representatives that will have to follow-up on the account with insurance companies to determine why the insurance denied the claim. This can cause delay in payment, rebilling, and more work for the follow-up representative.
Barry Folland In 2000 the Institute of Medicine (IOM) released its report “ Too Err is Human”, citing that as many as 98,000 people die per annum from medical errors and attributes to the eighth leading cause of death. The cost is estimated at between $17 and $29 billion a year, of which health care costs are one half. The Department of Health and Human Services did a survey in 2010 and found that 180,000 people die per year as a result of medical errors and infections. The health care industry has been behind a decade or more in attention to assuring basic safety. Safety is a critical first step in improving quality of healthcare.
For example, in 2006, the Institute of Medicine’s (IOM) report found that between forty four thousand and ninety eight thousand Americans die yearly as due to medical errors. Medication errors alone is the estimated culprit of over seven thousands deaths annually compared to the six thousand yearly deaths due to injuries in the workplace. Even though most of the debate on medical errors has been aimed at hospital settings, errors may happen in other settings like doctor offices, outpatient surgical facilities, nursing homes, and retail pharmacies. Total costs of medical malpractice resulting in injury are between seventeen billion and twenty nine billion dollars, with healthcare costs taking over fifty percent. Medicare reimbursed hospitals an added three hundred thousand dollars annually, or three tenth percent of annual Medicare hospital spending, for five kinds of adverse events.