Criterion 1: Diagnosis classification, care reimbursement, and the billing system
Explains the overall concept of diagnosis classification, care reimbursement, and the billing system used in the hospital, including two or more examples.
? Includes a thorough review of insurance company reimbursement procedures.
Criterion 2: Meeting patient needs
? Explains how the hospital will meet patient needs, priorities, and expectations including two or more examples.
? Includes a thorough explanation of the values of respect, compassion, justice, and community pride in the care of the patient.
Criterion 3: Violations
? Addresses each of the violations, including two or more examples of each: upcoding, duplicated charges, phantom charges, unbundling, and incorrect quantities.
? Includes a thorough explanation of what will be done so these violations will not occur again.
Criterion 4: Develops a contingency plan
? Develops a contingency plan for the future, including two or more examples.
? Includes a thorough explanation of how the hospital will be prepared in the future for similar emergency events.
Criterion 5: Quality of Delivery
? Narration is clear, well-articulated, well-paced, and appropriately projected.
? Visual aids are used creatively and appropriately to supplement the narration.
Criterion 6: Body Language
? Appropriate body language is used effectively to enhance persuasion.
? Good posture and eye contact are maintained appropriately throughout the entire delivery of the video.
Imagine you were appointed the Chief Financial Officer of your hospital, and you have a new crisis to confront. Your hospital received an unannounced visit from a CMS (Centers for Medicare and Medicaid Services) surveyor following a serious patient billing complaint. Your hospital is well-known both regionally and nationally for quality and safety, but the complaint threatens the hospital’s CMS enrollment, accreditation, and reputation. The surveyor determined that violations did occur, and the hospital has 90 days to resolve the issue or lose its Medicare funding. The violations include upcoding, duplicated and phantom charges, unbundling, and incorrect quantities.
You will create a plan for dealing with this crisis. The plan should consider current business processes, strategy, and communication processes to make the plan a reality. Also, consider how the crisis affects the staff and how you can reduce the amount of stress and pressure on them. Resolving the issue is just the beginning of the process. You need to determine if there was a process or system failure and figure out the solution to that failure. You should also develop a contingency plan for the future so the hospital will be prepared in the future for similar crisis events.
You need to explain the concepts of diagnosis classification, care reimbursement, and the billing system used in the hospital and by insurance companies for reimbursement for care received. You will explain how the hospital will meet patients’ needs, priorities, and expectations in a manner that exemplifies the values of respect, compassion, justice, and community pride. You need to explain the hazards of insurance, who pays for services, and the payment methods and plans available. Lastly, include the importance of proper medical billing and coding.
Instructions
Create either an audio recording or video recording at least 5 minutes in length to explain your planned proposal to deal with the violations and return the hospital into compliance within the 60 days given by CMS.
You will need to include:
- An explanation of concepts of diagnosis classification, care reimbursement, and the billing system used in the hospital and by insurance companies for reimbursement for care received.
- An explanation of how the hospital will meet patient’ needs, priorities and expectations in a manner that exemplifies the values of respect, compassion, justice, and community pride.
- Each of the violations upcoding, duplicated charges, phantom charges, unbundling, and incorrect quantities. Then, explain what will be done so these violations will not occur again.
- A contingency plan for the future so the hospital will be better prepared for similar crisis events.
Expert Solution Preview
Introduction:
In this proposal, we will address the crisis faced by a hospital after receiving a serious patient billing complaint resulting in the violation of upcoding, duplicated and phantom charges, unbundling, and incorrect quantities. The hospital has 90 days to resolve the issue or lose its Medicare funding. Our plan aims to deal with the violations and return the hospital to compliance within the 60 days given by CMS. This proposal will explain the concepts of diagnosis classification, care reimbursement, and the billing system used in the hospital and by insurance companies for reimbursement for care received. We will also explain how the hospital will meet patients’ needs, priorities, and expectations in a manner that exemplifies the values of respect, compassion, justice, and community pride. This proposal will then outline a contingency plan for the future to better prepare the hospital for similar crisis events.
Criterion 1: Diagnosis classification, care reimbursement, and the billing system
The hospital must have robust billing and coding systems in place to ensure accurate diagnoses classification, care reimbursement, and the billing system. The hospital needs to review all billing and coding procedures to identify weaknesses that could lead to billing errors. We will also provide additional training and education to coding staff to ensure accurate coding of patient diagnoses and treatments. We will also work with insurance companies to fully understand their reimbursement processes and procedures.
Criterion 2: Meeting patient needs
We will conduct internal patient satisfaction surveys to identify patient priorities and expectations. Our aim will be to address any gaps and improve our processes. We will also review our current care standards in light of our value system of respect, compassion, justice, and community pride, and make any necessary changes.
Criterion 3: Violations
We will review all charges and billing codes as an initial step to correct the identified violations. Additional training will be provided for coding staff to identify and avoid the risk of upcoding, duplicated charges, phantom charges, unbundling, and incorrect quantities. We will also hold a discussion with all medical and administrative staff about ethical standards and compliance.
Criterion 4: Develops a contingency plan
We will prepare a crisis management team to immediately address any emerging crisis. The team will identify key areas of risks and develop strategies for quick and efficient resolution in case of a billing complaint or other event. Additionally, we will continuously review the crisis management plan to ensure preparedness for future emergencies.
Criterion 5: Quality of Delivery
Our narration shall be clear, well-articulated, well-paced, and appropriately projected. We will use visual aids effectively to complement the narration and improve understanding.
Criterion 6: Body Language
We will maintain appropriate body language throughout the entire delivery of the proposal. Good posture and eye contact will be maintained to enhance persuasion.
Conclusion:
This proposal aimed to address the crisis faced by the hospital that violates upcoding, duplicated and phantom charges, unbundling, and incorrect quantities. Our plan requires robust billing and coding systems in place, patient satisfaction surveys, identifying patient priorities and expectations, and ethical codes. We will also provide additional training and education to coding staff and crisis management planning. Finally, our narration and body language will be clear and effective to improve overall delivery.
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