M. Wise Unit 1 Assignment
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School
Purdue Global University *
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Course
215
Subject
Health Science
Date
Dec 6, 2023
Type
docx
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3
Uploaded by ChiefTreeQuetzal32
HI215 Unit 1 Assignment
Morgan Wise
Purdue University Global
1.
What should WPS do with CMS to improve the process?
WPS needs to have more detailed billing to prevent CMS from paying for things
that are not covered and prevent overpaying as well. WPS needs to be willing to
work with CMS and improve their process for outpatient procedures.
2.
As an executive for the Wisconsin Physicians Service (WPS) Insurance Corporation, after
reviewing the case, write a response letter that addresses the issues. Include 3
recommendations, with supporting rationale, of how to improve the processes in your
response.
I represent Wisconsin Physicians Service (WPS) Insurance Corporation. There were some
concerns that we noted during a review. There were fourteen claims reviewed. Eight of the
fourteen claims were processed and paid correctly for outpatient services. The other six claims
resulted in incorrect excessive or outlier payments. The hospitals submitted an inflated number
of units along with related charges. This caused WPS to overpay the hospitals by 17,966. The
hospitals did not have the appropriate regulations in place for appropriate billing. Medicare
payment controls in the FISS also were not sufficient, which resulted in incorrect payments not
being detected. My suggestions for improvement would be a system to keep track of inventory,
so there is documentation of who many devices were used. The implementation of a compliance
officer in the hospitals who is dedicated to tracking devices and billing could help to prevent
error likes this. The Fiscal Intermediary Standard System (FISS) needs to evaluated. This should
have appropriate control in place to help ensure accuracies. The system is meant to help detect
discrepancies and may just need to be appropriately updated to function at the necessary level.
Hopefully, if some changes can be made these issues can be avoided in the future.
References
Harrington, M. K. (2019).
Health care finance and the mechanics of insurance and
reimbursement
(2nd ed.). Jones & Bartlett Learning.
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