Consider the following scenario:
Mercy Hospital in rural Southwest Ohio has had problems with patient collections for many years. With increasing deductibles and co-pays, the problem is expected to worsen, and the staff at Mercy Hospital need to find a way to address accounts with balances due to avoid worsening the problem. Mercy is a small hospital system with a limited number of support staff and a small budget dedicated to billing and collections. They have some options for increasing recovery of overdue balances and avoiding further revenue cycle issues. They could hire additional staff who would work exclusively with coding, billing, and recovery, or they could outsource their revenue management to an outside entity.
What is the best option for Mercy Hospital? What kind of information is at play in making this decision? As a healthcare management professional, it is important to have an understanding of the different components of the revenue cycle and how those components are interrelated. A properly managed revenue cycle can make or break a healthcare organization, so decisions surrounding it are often of great importance.
This week, you will examine the components of the revenue cycle and the different departments that play a part in each. You will also analyze a case study dealing with upcoding, payment error prevention, and the implications of fraud and abuse.
Assignment: Coding Accuracy Case Study
The importance of accuracy in medical coding cannot be overstated. Proper coding leads to proper payment. Unfortunately, some providers and organizations attempt to manipulate revenue by coding for more services at a higher level of complexity in order to get larger reimbursements from insurance companies. This practice is known as “upcoding.” The Healthcare Financing Administration (HCFA) does monitor for upcoding, but its processes are not adequate, and many upcoded claims for diagnosis-related groups (DRG) are overlooked.
In this Assignment, you consider a case study about the HCFA’s monitoring of upcoding and develop an action plan for improving the monitoring process. You also discuss the elements that should be included in a payment error prevention program and the implications of fraud and abuse in healthcare.
To prepare for this Assignment:
- Review this week’s Learning Resources.
- Read the document, “Case 9: Coding Accuracy,” located in this week’s Learning Resources.
- Reflect on how DRG upcoding was detected through electronic claims data.
The Assignment (2- to 3-page paper):
After reading the case study thoroughly, write a paper in which you respond to the following:
- Propose an action plan outlining what the Healthcare Financing Administration (HCFA) should do to monitor DRG upcoding.
- Recommend key elements to be included in a payment error prevention program.
- Explain the implications of fraud and abuse for this case. Then, discuss the broader implications of fraud and abuse. What are the consequences, and who is impacted?
Provide specific examples in your paper. Support your post with the Learning Resources and at least one current, outside scholarly article (less than 5 years old).
Required helpful websites: