Kristin_Bautista_Task 3 Errors and Legal Issues_5.29.23

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1 ERRORS AND LEGAL ISSUES Kristin Bautista Western Governors University Dr. Kristin Minter May 29, 2023

2 A1. Financial impact . The claim was turned down because the Blinatumomab shot was coded and billed for instead of the blood transfusion. As you review the patient record, the Blinatumomab is the proper infusion, and observe that it costs $6,900 more than a blood infusion. Further investigation showed that the blood infusions category's dropdown menu was alphabetical, resulting in the selection of blood transfusions instead of Blinatumomab. This error has occurred on six occasions throughout the year following a thorough examination of prior claims. This error shows the possibility of causing established financial inadequacies and elevated expenditures for the hospital. An inaccurate coding pattern exists for the administration of blood infusion being coded and billed for blinatumomab infusion. Incorrect billing may lead to substantial repercussions on the financial viability of healthcare organizations. ( Centers for Medicare & Medicaid Services, 2019) The inadvertent selection of inaccurate data, fields, or codes is standard. Insurance providers could decline claims if the codes used are invalid. Incorrect coding might lead to insurance claim denials. Hospitals must provide complete documentation to earn appropriate compensation. When documentation is insufficient to support service payments, claims must match the information provided. In this situation, there may be challenges due to incomplete paperwork, a lack of evidence, or insufficient medical justification, resulting in the rejection of the request. ( Centers for Medicare & Medicaid Services, 2019) The optimization of procedures holds significant importance for service providers operating under such circumstances. Individuals working in medical coding demonstrate the capacity to predict procedural inaccuracies, reducing the probability of claim rejections. The implementation

3 of billing corrections has the potential to increase healthcare costs. The hospital's expenses could escalate because of essential repairs. Updating the billing records and communicating with the patients or insurers can fix the issue. This occurrence shows the capacity to reduce the resources designated for patient care and quality improvement activities within hospital environments. The frequency of billing errors is a significant cause for concern. ( Centers for Medicare & Medicaid Services, 2019) The matter of concern pertains to the potential impact of billing errors on the financial resources allocated to hospitals. Payors can reject claims that are fraudulent, excessive or lack proper support. Incomplete claims often cause payment delays. Delays in hospital operations can harm the revenue generated by the institution. If billing inaccuracies decrease income, hospitals may encounter difficulties in procuring new equipment, expanding their range of services, or recruiting and retaining highly qualified medical personnel. There may be a negative effect on the ability to afford hospital care. Billing errors may result in overpayments for hospitals. Blinatumomab may have been utilized incorrectly as a replacement for blood transfusions, which could result in overcharging. Increasing the level of repayment has the potential to result in a reduction in hospital profits. ( Centers for Medicare & Medicaid Services, 2019) Most overpayment incidents arise when a patient or their insurance provider reimburses healthcare providers with an amount that exceeds their entitled reimbursement rate. This phenomenon can occur due to a multitude of factors. Although most overpayments are accidental, there are instances where they are deliberate. A healthcare professional who needs to refund an excess payment jeopardizes their financial income and their standing in the industry. Even though medical coding errors may be accidental, fixing them and refunding the correct

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4 parties is crucial. It is important to note that failure to provide a refund or credit to a patient or insurance provider for an overpayment is deemed a criminal offense. ( Centers for Medicare & Medicaid Services, 2019) Adherence to legal mandates and proficient handling of billing complexities are imperative for healthcare facilities. Precise billing and coding are essential for healthcare providers to prevent any potential billing complexities. Financial deficits may arise due to irregularities in the billing procedures of hospitals. The magnitude of penalties may vary significantly depending on the nature of the offense, ranging from thousands to millions of monetary units. In a dispute, the hospital may face potential legal and litigation expenses. The hospital's licensure is susceptible to being revoked or restricted regarding the services offered. ( Centers for Medicare & Medicaid Services, 2019) A2. Quality-of-care and legal issues related to the data-entry error . Preventing financial losses and legal problems by immediately validating incoming data is less expensive than fixing or ignoring errors. Upon conducting a thorough analysis of the patient's medical history, it has been confirmed that the administration of blinatumomab is the correct medication. It is significant to note that the expense associated with this infusion is $6,900 greater in comparison to that of a blood transfusion. Upon reviewing the database, it has been discovered that this identical error has occurred on six separate occasions throughout the current year. (Wolf & Hughes, n.d.) An apparent trend has been noticed in the coding and billing of blood infusions in relation to blinatumomab infusions. It was found that a drop-down menu for infusions was available, with

5 the choices listed in alphabetical order, while visiting the electronic health record's drug reconciliation area. The administration of blinatumomab infusion precedes that of blood infusion. The occurrence of data input errors has the potential to negatively impact the hospital's reputation for providing better healthcare services. Medical errors have the potential to negatively impact a hospital's reputation and decrease patient trust, owing to the rigid patient care standards that must be upheld. A hospital is suffering from patient attrition and financial losses. The adverse effects of media exposure and public scrutiny on the hospital's reputation may result in legal and financial ramifications. The occurrence of data entry errors may result in significant legal consequences. It is imperative for medical record keepers to maintain a high level of accuracy in their documentation, as failure to do so may result in legal repercussions. The hospital's claim was rejected due to a data input error. (Wolf & Hughes, n.d.) Patients demonstrate a desire to trust that the implementation of efforts to enhance quality and collaborative learning will successfully reduce the occurrence of errors. Healthcare professionals who fail to comply with data entry and medical record maintenance standards may be subject to legal action by regulatory bodies. In the event that the data entry error in the given scenario signifies a more significant issue, the institution may face regulatory and financial penalties. The financial and reputational standing of the hospital may be negatively impacted. The patient or their family may sue the hospital if this error harms them. Legal fees, settlements, and hospital reputation damage could ensue from the above scenarios. (Wolf & Hughes, n.d.) Healthcare providers must keep accurate and up-to-date medical records to prevent legal risks and improve services. Medical malpractice lawsuits are filed when doctors, nurses, and other healthcare professionals harm patients. If a data entry error harms a patient, the hospital may be

6 sued for medical malpractice. The hospital must follow rules and prove the incident was isolated to prevent future errors. In addition to medical malpractice lawsuits, manipulating patient data can result in legal and financial penalties. If a healthcare professional changes a medical record with the intention of concealing malpractice or fraudulent billing, they may face charges of healthcare fraud. Healthcare fraud is a serious violation that may result in conflicts over insurance claims, financial sanctions, imprisonment, and the revocation of medical credentials. The occurrence of denied insurance claims resulting from erroneous medical records may lead to disputes among patients, healthcare providers, and insurance companies. Healthcare providers who fail to comply with the input of data and documentation of medical regulations may face legal action from regulatory bodies. The hospital may face penalties due to inaccuracies in data entry. This could negatively impact the hospital's financial and reputational standing. (Wolf & Hughes, n.d.) Medical practitioners must maintain precise medical documentation to mitigate legal complications and enhance the quality of patient healthcare. The initiation of medical malpractice litigation occurs when healthcare professionals, including physicians, nurses, and other medical personnel, cause harm to their patients. If a patient experiences harm due to an error in data input, the hospital may face potential legal ramifications for medical malpractice. The hospital must adhere to established protocols to mitigate analogous errors and ascertain that the incident was an isolated event. Intentional or deceptive inaccuracies documented in individuals' medical records may lead to legal ramifications for medical negligence and financial sanctions. Healthcare fraud is a phenomenon that may transpire when a healthcare professional alters a medical form intending to conceal illicit activities or deceitful billing practices. Healthcare fraud is a grave violation that may result in incarceration, monetary penalties, and the

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7 annulment of professional credentials. Inaccuracies within medical documentation have the potential to give rise to conflicts about insurance claims. The existence of inaccurate medical records may lead to the potential denial of insurance claims, resulting in disputes among patients, healthcare providers, and insurance companies. (Wolf & Hughes, n.d.) Maintaining precise and current medical records is imperative for diagnosis, treatment, and therapy. Collecting, validating, maintaining, retrieving, analyzing, and reporting data necessitates the application of analytical thinking to healthcare performance standards. The Health Information Management system is designed to enhance medical data organization, thereby mitigating the risk of data entry errors and improving treatment outcomes. The practice of data governance entails the involvement of dedicated personnel who are responsible for making informed decisions regarding information management. Additionally, these individuals are tasked with establishing a comprehensive framework for technology education, training, auditing, and compliance. The health information management personnel possess the ability to assess electronic health records and other technological frameworks that augment the establishment's all-inclusive data repository. (Wolf & Hughes, n.d.) A3. Corrective action plan to ensure that the error does not recur. Corrective action plans are implemented to address issues of compliance within healthcare institutions. The term "corrective action" pertains to the actions a governing body takes to address inaccuracies and rectify issues related to policies or billing requirements promptly and appropriately.

8 To reduce the frequency of claim rejections and billing errors, implementing a remedial approach is advisable to prevent their occurrence. It is imperative for a hospital to: • Choose appropriate members for the corrective action team. It is recommended that the facility convene a team of experts, comprising HIM specialists, coding specialists, clinical documentation improvement specialists, and IT specialists, to examine the issue at hand and devise a resolution. • Identifying problematic areas within an organization typically involves the detection of violations by regulatory bodies or third-party payors, such as Medicare or Medi-Cal. • Assess the issues at hand, analyze their effects on your institution, and consider the outcomes that may arise from failure to adhere to regulations. Please provide more context or information about what you are referring to. Without additional information, I cannot accurately rewrite the user's text to be academic. It is recommended that the team conduct an analysis of medical records, documentation, and coding practices in order to identify any potential issues or deficiencies. This phase will aid in ascertaining the magnitude of the problem and the extent of the required remedial action. • Determine the key roots of the identified concerns, regardless of whether they are superficial inaccuracies or issues stemming from procedures, methodologies, frameworks, or societal norms. Identify the fundamental reason for the error rather than solely addressing the superficial cause, and refrain from utilizing any expedient methods. It is imperative for the team to conduct an analysis of the underlying cause of the issue and identify the various factors that have contributed to it.

9 • Formulate a comprehensive strategy to address the issues at hand, enhance the relevant procedures or techniques required to rectify the problem, address the underlying cause, assess the efficacy of the proposed solutions, and prevent potential occurrences of comparable nature in the future. • Generate potential solutions for each identified error or pattern of errors. It is advisable to gather all ideas, even if some of them are not practical or put into action. The identification of each instance of error or pattern of errors should serve as a catalyst for the team to engage in discourse regarding prospective remedial actions. It is advisable to collect unfeasible or unviable proposals, as they may offer novel insights or indicate potential remedies. • Identify the cost-benefit analysis to determine the most cost-effective corrective measures. Evaluate the potential advantages and disadvantages of each proposed remedial action; it is recommended that the team conduct comprehensive cost-benefit research. They are prioritizing. • Execute the proposed course of action with efficiency, comprehensiveness, and efficacy. Establishing feasible deadlines, objectives, and milestones is recommended. It is recommended that the team establish feasible timelines, objectives, and performance indicators for corrective actions. During this stage, specific milestones are established to track progress and evaluate the effectiveness of the plan.

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10 • Provide a detailed account of implementing your course of action plan, including the methods used to communicate it to employees, the training programs introduced, and the plan's effects on your professional practice. • It is recommended to review the problematic areas after implementing the action plan to ensure that the issues have been resolved. This can be achieved by conducting periodic effectiveness checks and seeking the assistance of external consultants and auditors. • It is essential for the team to consistently evaluate and monitor the progress of the corrective action plan to ensure its efficacy. Metrics and significant performance indicators can be employed to oversee the plan's effectiveness and detect any future modifications or adaptations that might be necessary. Through implementing these measures, the healthcare facility can develop a comprehensive and effective remedial strategy that addresses the root causes of the error and prevents its recurrence. B. Explain the legal requirements for pharmaceutical reimbursement by doing the following: 1. National Drug Code (NDC) to the coding function. The Food and Drug Administration (FDA) inputs the complete National Drug Code (NDC) and its associated information into the designated database. The National Drug Code (NDC), a unique three-digit code, classifies and documents pharmaceutical products. The tool can identify all medications intended for human use. The selection of the blood infusion for blinatumomab infusion was made by coding and billing, with the available options being presented alphabetically within the infusion drop-down box. The administration of blinatumomab infusion comes before that of blood infusion. The denial of the claim was attributed to an inaccurate

11 National Drug Code (NDC) entry in the electronic health record (EHR) system. (Miller & Fox- Smith, 2012) The National Drug Code (NDC) identifies pharmaceutical manufacturers, products, and packaging sizes. Labeler, development, and packaging codes comprise the code. Product codes identify the medication and its strength, whereas labeler codes identify the maker or distributor. The package code specifies packaging size and attributes. Financial invoicing and compensation require NDC coding. Invoicing and reimbursement require NDC coding. NDC codes verify that the drug invoiced matches the medication provided, ensuring appropriate billing and payments. An improper electronic health record system NDC code caused the insurance company to deny the claim. (Miller & Fox-Smith, 2012) Professionals and institutions making drug-related claims, particularly about substances categorized under the letter J or Q, must provide the National Drug Code (NDC) number, quantity, and unit of measure. Compliance with the National Drug Code (NDC), quantity, and team of measurement will also be required. Inaccuracies in the NDC number, amount, and unit of measure will likely invalidate your claim. Filing a clean claim within the deadline is crucial. The billing issue highlights the importance of precise National Drug Code (NDC) categorization for billing and compensation. Each prescription has an 11-digit National Drug Code (NDC) for invoicing and reimbursement. Inaccurate NDC code entries invalidate claims. Healthcare firms must teach staff about NDC coding and design EHR systems to ensure code accuracy. EHRs validate National Drug Code (NDC) coding. Quality management in coding and billing helps improve NDC coding accuracy. This approach should include regular claim audits and

12 evaluations to catch and fix errors. The software can automate healthcare coding, reducing errors. The software can notify employees of NDC code changes. (Miller & Fox-Smith, 2012) Healthcare billing and payment processes require cross-departmental collaboration. Pharmacy and billing divisions must collaborate to integrate National Drug Codes (NDCs) accurately. Meetings and training can improve communication and NDC coding knowledge. These strategies could expedite healthcare billing and reimbursement while ensuring timely patient care. Interdepartmental billing and payment cooperation are essential in healthcare facilities. Pharmacy and billing must collaborate to load NDCs into the system. Meetings and training improve communication and employee understanding of NDC coding accuracy. These safeguards help healthcare organizations streamline billing and reimbursement and provide timely care. (Miller & Fox-Smith, 2012) B2. Steps to take to report suspected fraud and abuse in collected data. Health Information Management (HIM) professionals' functions provide safe and high-quality patient care. HIM experts ensure patient safety and quality. High-quality, cost-effective healthcare requires collaboration between stakeholders and experts. Due to a lack of uniformity, organization, and efficacy, some patients receive excellent care while others receive terrible care. Drug safety, medical errors, healthcare-acquired illnesses, IT failures, and fragmented delivery systems undermine healthcare quality and safety. (Montrose, J., et al. 2018) HIM procedures enable exact data allocation, procurement, inspection, healthcare operations, patient welfare surveillance, and unbiased data for informed decision-making. HIM professionals and executives get along. Collaboration improves patient care. Health information managers safeguard electronic medical records. Healthcare providers collaborate on admission and

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13 discharge in this profession. Health data rules must be observed. Electronic medical records must be secure and private. Jobs involve system or file storage changes. Healthcare-specific software is assessed, arranged, and executed. (Montrose, J., et al. 2018) Organizations use internal reporting to evaluate performance. It's finding and reporting fraud and abuse. Health information management specialists must thoroughly analyze documents and knowledge to uncover problematic behavior. Precision and analytical reasoning are needed. The specialist must check the patient's medical and billing records for errors. Pharmaceutical charges and delivery data may help match prescription quantities and frequencies to the patient's medical condition and treatment regimen. HIM Specialists must carefully record suspicious activity. (Montrose, J., et al. 2018) This record should include suspected fraud or abuse, the data or evidence that raised suspicion, and any pertinent information. This paperwork will prove fraud or misbehavior in future investigations or legal processes. (Montrose, J., et al. 2018) 1. Establish parameters for the audit. It is imperative to determine the types of services to include in one's assessment. Individuals have the option to conduct an audit solely on evaluation and management services or to expand the scope of the audit to include surgical procedures, modifiers, and ancillary testing. Commencing a baseline review is a judicious strategy for individuals who possess no antecedent exposure to auditing. This audit has the potential to offer significant insights into the practices of medical recordkeeping and coding. (Montrose, J., et al. 2018)

14 2. Determine the primary stakeholders involved in the situation. Frequently, internal audits are conducted by in-house coders who possess expertise in interpreting policies and exhibit a favorable perspective. It is imperative to involve physicians in the planning process to ensure the buy-in and collaboration of all relevant stakeholders. Securing authorization from the compliance officer, administrator, and legal advisors is a crucial prerequisite prior to commencing an audit. (Montrose, J., et al. 2018) 3. Gather current coding guides, National Correct Coding Initiative updates, and CMS rules. Select the appropriate CMS Documentation Guidelines for the evaluation and make sure the E&M Audit Worksheet is available. Some healthcare practitioners or specialists may use unique documentation formats. CPT code audit worksheets may be needed, depending on the services audited. Diagnostic imaging report checklists, operational word criterion checklists, and time- based coding worksheets are examples of worksheets. (Montrose, J., et al. 2018) 4. Obtain duplicates of the corresponding CMS claim form in order to verify the precision of the invoiced services. By means of scrutinizing these documents, it is feasible to identify problematic domains, such as inaccurate data input, utilization of outdated code sets, or insufficiently arranged surgical CPT codes, which could result in inappropriate disbursements. (Montrose, J., et al. 2018) 5. The basic coding review should include, at a minimum, verification of the application of Current Procedural Terminology (CPT) codes, which includes the determination of the level of Evaluation and Management (E&M) visit assigned, identification of services that are either not documented or inadequately documented, proper utilization of modifiers, accuracy of diagnosis

15 codes, and confirmation of medical necessity through the source document. (Montrose, J., et al. 2018) 6. Essential regulatory components may be assessed. The domains above may involve validating physician and other provider signatures and authentications, including electronic signatures and patient identifiers such as full name, date of birth, etc. These domains may include CMS Advance Beneficiary Notice form use, 'incident-to' requirements, and laboratory and radiology order verification. (Montrose, J., et al. 2018) 7. After the audit, create a summary with raw data. Use a simple spreadsheet or dashboard report for provider feedback sessions. The data columns should show CPT and ICD-10-CM codes before the audit, physicians who coded, and coder audit team regulations afterward. To provide helpful feedback on appropriately coded encounters, include a review code. Combining review codes shows common documentation errors like overcoming, under-coding, and missing signatures. Mistakes and issues are often addressed. (Montrose, J., et al. 2018) 8. Arrange medical visits to give comments and suggestions. The coder should let the physician explain their coding decisions and provide more facts to help them understand clinical terms. Personalizing case examples enables review and debate. (Montrose, J., et al. 2018) 9. After the audit, write recommendations. A more frequent and focused audit, updated documentation templates, and specific CPT or ICD-9-CM coding instructions are suggested. Identifying claims that need correction or reimbursement is important. (Montrose, J., et al. 2018) 10. Compliance management requires assigning a responsible person for each compliance area and documenting follow-up. Regular monitoring of formal training programs, individualized

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16 mentoring, periodic re-audits, and practice policy and procedure revisions are essential. After addressing the previous concerns, a systematic method to supervise these domains is necessary. (Montrose, J., et al. 2018) B3. The importance of a pharmacy revenue cycle internal audit . The scenario concerning medication reconciliation in the electronic health record (EHR) involves dispensing a blood transfusion. The hospital invoiced for a blood transfusion, which is relatively less expensive than the blinatumomab infusion. Without this discovery, the hospital would have felt an audit of its own. In this scenario, minor errors and oversights can result in a substantial loss of pharmacy revenue, which may escape the system and adversely impact the organization's profitability. These issues could cause significant financial detriment to the entity, which could prove challenging to recover. To address such scenarios, a healthcare organization can proficiently and thoroughly assess and examine the pharmacy revenue cycle from its inception to its conclusion. (Miller & Fox-Smith, 2012) This undertaking involves a comprehensive analysis beyond a simple assessment of financial aspects such as procurement, pricing, invoicing, and remittance. The system must identify covert coding, pricing, and payment inaccuracies. Therefore, the undertaking requires a wide range of skills, including the cooperation of individuals from the fields of pharmacy, finance, and regulatory compliance, as well as insurance and payment experts working as an interdisciplinary team. (Miller & Fox-Smith, 2012) Compliance with legislation and financial considerations requires correcting billing errors. Billing errors can deny or prohibit claims, costing the company money. Billing errors can

17 lead to overcharging, undercharging, and legal and regulatory violations. An internal audit can help identify billing code problems, insufficient documentation, and other issues that could result in claim denials or rejections. By promptly identifying problems, healthcare organizations can take corrective measures to prevent a repeat. (Miller & Fox-Smith, 2012) A pharmaceutical revenue cycle internal audit can help pinpoint areas that could use streamlining and efficiency improvements. The audit could unveil errors or repetitions in the billing process that can be fixed to reduce processing times and expedite reimbursement. The company can enhance the effectiveness of its revenue cycle and increase revenue by recognizing and resolving these problems. The audit may also point out chances to use new technology or automate specific operations to optimize the revenue cycle process further. Increasing revenue cycle effectiveness can boost the organization's financial results and enhance patient care. (Miller & Fox-Smith, 2012) A revenue cycle internal audit can reduce fraud and abuse in some ways. Determine any anomalies or discrepancies in billing trends that might point to copying. To prevent fraud, the company must identify and address problems such as upcoding, paying for services not provided, or sending duplicate invoices. Healthcare organizations can boost patient trust, confidence, and reputation in the field by fostering a culture of integrity and ethical behavior. To ensure that all treatments and services billed were necessary and adequately documented, conducting an internal audit that confirms compliance with applicable regulations and laws is essential. This will also ensure that the company follows ethical and moral billing procedures. (Miller & Fox- Smith, 2012)

18 Pharmacy management demands revenue cycle optimization. It improves financial performance and patient care. Internal revenue cycle evaluations might identify areas that need simplification and consolidation to improve efficiency. An audit may discover billing system errors or unnecessary steps, allowing corrective efforts to speed up reimbursement and enhance operational efficiency. The audit may reveal opportunities to use new technology or automated processes to optimize the revenue cycle. This could boost revenue. (Miller & Fox- Smith, 2012) Internal revenue cycle audits may reduce fraudulent activity. The technology can initially detect billing trends that imply fraud. This may involve upcoding, invoicing for services that were not supplied, or submitting several invoices for the same service. An organization can address these problems and avoid fraud by taking proper actions. Internal audits can also examine the company's billing ethics. The procedure may involve verifying the necessity and accuracy of all patient treatments and services and assuring the company's compliance with relevant regulations and legislation. A cultural framework emphasizing integrity and ethics can boost patient trust, confidence, and the reputation of healthcare facilities. Pricing errors, incorrect product billing, poor coding, and inadequate charge descriptions can cause pharmaceutical revenue losses. Specialty drug prices and outpatient pharmacy billing errors often cause revenue loss. Pharmacy revenue cycle audits might reveal regulatory compliance concerns. The aim is to identify common billing errors made by government agencies or payment processors. A thorough examination of the pharmacy department's services can reveal opportunities for operational efficiencies and service expansion. Consider discharge medication reconciliation, specialized pharmacy, and ambulatory clinical pharmacy services. These improvements could be self-sustaining if income rises significantly. Modern payment mechanisms are complicated,

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19 making pharmaceutical financial transactions more likely to have anomalies and transfer errors. Errors can affect pharmaceutical procurement, patient billing, remuneration, and record-keeping. Pharmacy and financial analysts may need to catch these errors across numerous phases. (Miller & Fox-Smith, 2012) B4. Three important points when conducting a pharmacy revenue cycle internal audit. 1) Analyzing the services offered by the pharmacy department can significantly enhance operational efficiency and service delivery. Audits can identify discrepancies or inaccuracies in billing to prevent rejected claims, financial losses, and legal concerns. Audits should focus on invoicing faults and differences to avoid denied claims, financial losses, and legal problems. (Miller & Fox-Smith, 2012) 2) Collaboration between pharmacy integrity staff and the compliance department is essential to ensure compliance programs and reporting information is shared. (BC Advantage, 2010) 3) Healthcare compliance audits and conducting internal audits should identify training gaps and identify revenue cycle inaccuracies. Reports should include regulatory changes, controls, rule evaluations, insufficient training, policy updates, risk assessments, and other important information. (BC Advantage, 2010) a. Justify why these points are important to consider. The conduct of an internal audit of the pharmacy revenue cycle necessitates the consideration of various significant criteria. There are three crucial factors to consider. 1. The audit can uncover prospects for enhancing the revenue cycle by implementing novel technologies or automated procedures. Errors can impact various aspects of pharmaceutical procurement, patient billing, compensation, and paperwork. The primary

20 objective of the audit should be to identify any discrepancies or inaccuracies in billing. Pharmaceutical revenue losses may arise due to inaccuracies in pricing, product invoicing, coding, and charge descriptions. A professional audit conducted by a specialist can facilitate the detection and rectification of inaccuracies, ensure adherence to legal and regulatory mandates, and enhance revenue generation. The audit should concentrate on invoicing faults and discrepancies to prevent rejected claims, financial losses, and legal concerns for the organization. Conducting an audit has the potential to identify errors in the billing system or redundant steps, resulting in expedited reimbursement and improved operational efficacy. The occurrence of pricing and billing inaccuracies in hospital specialty medicine harms revenue. The objective is to discern inaccuracies in government billing and payment processing. An analysis of the services provided by the pharmacy department can be conducted to enhance operational efficiency and optimize service delivery. Implementing discharge medication reconciliation, specialty pharmacy, and ambulatory clinical pharmacy should be considered. Employing contemporary payment technologies increases the probability of encountering anomalies and transfer difficulties in financial transactions within the pharmaceutical industry. (BC Advantage, 2010) 2. Collaboration between the pharmacy integrity staff and the compliance department is necessary to oversee and evaluate processes throughout the revenue cycle. Writing policies and procedures is an important step in establishing a compliance program, but these policies need to be enforced and regularly updated to be effective. This is where having a designated compliance professional becomes beneficial. The role of the compliance professional is to remain up to date with new requirements and ensure this information is effectively communicated to all necessary employees. This cooperation helps create rules and procedures, train staff, and manage compliance issues. Healthcare professionals must report compliance

21 issues immediately. The compliance program should include the reporting mechanism and beneficiaries for the problem. Healthcare practitioners must be able to access compliance programs and report information. They should also be ready to share this information with other staff members. The healthcare practitioner may interview staff to gather information on possible unreported conformance issues or to learn more about suspected cases. A mitigation strategy is developed after an audit identifies revenue cycle risk areas. This usually involves the compliance committee and the affected department(s). The healthcare practitioner should be able to advise on risk mitigation and work in a primary or secondary role. (BC Advantage, 2010) 3. Compliance audits help clinical and non-clinical divisions identify and address significant business risks and compliance issues. Internal audits help healthcare firms meet regulatory requirements in patient access, documentation, charge capture, and patient financial services. They resolve audit concerns, train personnel on legal conditions, organizational policies, and protocols, and execute remedial measures. Teaching protocol and communicating crucial criteria Audits should evaluate staff education and training. Education and training determine how well personnel grasp their revenue cycle tasks and the legal and regulatory limits that govern billing operations. The Office of Inspector General (OIG) recommends annual billing staff training after primary training. A staff education and training audit can help identify areas that need more training. All employees need to be competent and ethical. Efficient, accurate, and legal revenue cycle processes are achieved through proper education and training, ensuring compliance with regulatory requirements. Documentation must be accessible, adequate, acceptable, qualified, relevant, and accurate. Thus, the audit must assess staff education and training. Inadequate training and instruction can lead to staff members needing to understand crucial protocols and regulations or the importance of precise and prompt documentation.

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22 Revenue cycle inaccuracies and inefficiencies can arise from various factors, and conducting a self-assessment across multiple domains is essential. It's crucial to pinpoint the specific type of error to expedite fixing self-auditing errors. Throughout the auditing process, note how often inaccuracies occur and the total number of errors. This information enables healthcare companies to assess their compliance programs. Reports should include details on necessary regulatory changes, corresponding controls that meet new regulatory requirements, the outcome of current rule evaluations, insufficient training, the number of policies requiring updates, risk assessments, and other vital information. (BC Advantage, 2010) References

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23 BC Advantage (2010, March 18). Conducting an internal coding audit: 10 must know tips for the auditing team. BC Advantage - Billing-Coding, Inc https://www.billing-coding.com/full-article.cfm?articleID=3466 Centers for Medicare & Medicaid Services. (2019, Nov 18). 2019 estimated improper payment rates for centers of medicare & medicaid services (cms) programs. CMS.gov https://www.cms.gov/newsroom/fact-sheets/2019-estimated-improper-payment-rates- centers-medicare-medicaid-services-cms-programs Miller, D. E., & Fox-Smith, K. (2012). Pharmacy revenue cycle audits can bring unexpected returns: hospitals should be aware that seemingly small errors in pharmacy revenue cycle processes can cause them to lose substantial dollars from their bottom lines. Healthcare Financial Management, 66 (10), 78-83. https://pubmed.ncbi.nlm.nih.gov/23088058/ Montrose, J., Courtney, M., Rector, H., Coffin, J. (2018, December 12). Medicare fraud and abuse. https://www.medicaleconomics.com/view/medicare-fraud-and-abuse Schmidt, W. (2023, May 4). Unnecessary medical billing errors: Simple breakdown for new providers and investors. PCG Software, Inc. https://www.pcgsoftware.com/financial-impact-of-medical-billing-errors Wolf, Z.R. & Hughes, R.G. (n.d), Chapter 35, error reporting and disclosures. Patient Safety and Quality: Evidence-Based Handbook for Nurses. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK2652/

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Kristin_Bautista_Task 3 Errors and Legal Issues_5.29.23

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