c807 task 2 use 4

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Western Governors University *

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C807

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Information Systems

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Dec 6, 2023

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Uploaded by DeanLapwing6244

C-807 Healthcare Compliance Nov 9, 2023 .

Management Communication – Task 2 2 Contents A1. Necessary Corporate Components of a Compliance Plan ...................................................................... 3 A2. Roles and Responsibilities of the Staff Member .................................................................................... 4 A3. Roles and Objectives of TJC ................................................................................................................... 5 A4. Reporting Coding Noncompliance ......................................................................................................... 6 B1. Formal Request for Internal Audit ......................................................................................................... 6 B2. Formal Request for External Audit ......................................................................................................... 7 C. Resources ................................................................................................................................................ 9

Management Communication – Task 2 3 A1. Necessary Corporate Components of a Compliance Plan Listed below are the seven necessary components of a corporate compliance plan: 1. Written policies and procedures: This component of a compliance plan is the development of clear, comprehensive policies and procedures that outline the organization’s commitment to specific compliance requirements. This aim of written policies and procedures is to provide the employees and business associates with a clear expectation of their behaviors and organizational processes, ensuring that everyone understands what is required of them. These standards are also designed to deter unlawful activities (Safian, S. 2009). 2. Compliance Officer and Compliance Committee: The appointment of a compliance officer and the establishment of a compliance committee ensures that individuals are responsible for overseeing and managing the compliance program. In a healthcare organization, it is essential for the compliance director to hold a prominent executive position and possess the necessary authority to implement and enforce policies and procedures (Safian, S.2009). The compliance officer and committee are responsible for monitoring compliance activities, conducting assessments, and implementing corrective actions. 3. Training and Education: This component emphasizes the importance of training and educating employees on compliance policies, regulations, and ethical standards. It ensures that staff members are knowledgeable about their roles and responsibilities in maintaining compliance. 4. Effective communication: this component focuses on establishing channels of communication to facilitate the reporting of compliance concerns, such as an anonymous hotline or designated compliance officers. It encourages open dialogue and ensures that the employees feel comfortable reporting potential noncompliance.

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Management Communication – Task 2 4 5. Auditing and Monitoring: To maintain awareness of established effectiveness of established policies and procedures, it is essential to implement a monitoring system that incorporates internal safeguards and establish a reporting system for all facility members to identify potential violations that require further investigation (Safian, S. 2009). Regular auditing and monitoring activities will help to identify potential compliance issues and assess the effectiveness of the compliance program. This component involves conducting internal audits, risk assessments, and ongoing monitoring to address any gaps or areas of concern proactively. 6. Enforcement and Discipline: This component emphasizes the need for consistent enforcement of compliance policies and appropriate disciplinary actions for noncompliance. It helps maintain accountability and fosters a culture of compliance within the organization. 7. Response and Prevention: This component focuses on prompt response to compliance issues, investigating them thoroughly, and implementing corrective measures. It also involves reviewing and updating the compliance plan to adapt to changing regulations and standards. When it is necessary, policies must be adjusted to close unforeseen loopholes or to communicate new regulations (Safian, S. 2009), A2. Roles and Responsibilities of the Staff Member Compliance Officer 1. The compliance officer is responsible for the creation and implementation of a detailed compliance program, the maintenance of the program's effectiveness, and the making of revisions as needed (Safian, S. 2009). 2. They assist in policy development, risk assessment, internal audits, and review.

Management Communication – Task 2 5 3. Develop and coordinate educational and training programs regarding elements of the compliance program such as appropriate documentation, and accurate coding. 4. Review claims denials and rejections related to coding and medical necessity issues. When it is necessary implement a corrective plan such as an educational training program to prevent similar rejection or denial from reoccurring. 5. The compliance committee should establish effective strategies for detecting and investigating alleged violations, which includes the launching of hotlines, protection for whistleblowers, and other reporting systems (Safian, S. 2009). HIM Compliance Specialist 1. Supervise and track the execution of the HIM compliance program. 2. Creates and manages educational and training initiatives for personnel involved in the HIM compliance program, including HIM coding staff, physicians, billing personnel, and ancillary departments. These programs focus on essential aspects of the program, such as proper documentation and precise coding. 3. Keeps records of attendance and documentation for HIM training programs 4. Analyze coding reimbursement profiles, comparing them to national and regional benchmarks to identify discrepancies that may necessitate additional investigations. The Outpatient Consultants/Charge Master Audit Consultant 1. The outpatient consultants perform audits of the outpatient medical records to assess coding accuracy, documentation completeness, and compliance with coding guidelines. 2. The identifies any discrepancies between the documented clinical information and the assigned codes, ensuring that the codes accurately capture the complexity and specificity of the services rendered.

Management Communication – Task 2 6 3. They compile audit findings, prepare reports, and maintain documentation of their audits, ensuring that all necessary information is accurately recorded. 4. They must stay updated on changes in coding guidelines, regulations practices specific to outpatient services to ensure their audits align with the current requirements. Inpatient Audit Consultants 1. Inpatient audit consultants review medical records, including physician’s orders, progress notes, and discharge summaries, to assess the accuracy and completeness of coding and documentation. 2. They evaluate the hospital’s compliance with coding regulations, including those set by the government and third-party payers to ensure that coding practices align with the appropriate guidelines. 3. They compile audit findings, prepare reports, and maintain documentation of their audits, ensuring that all necessary information is accurately recorded (Safian, S. 2009). 4. Inpatient audit consultants work closely with hospital staff which includes the physicians, medical coders, and compliance officers, to address any coding and documentation issues and implement the necessary improvements. A3. Roles and Objectives of TJC The Joint Commission (TJC) is an independent, nonprofit organization that accredits and certifies healthcare organizations in the United States. It sets standards and evaluates healthcare compliance with those standards to ensure the delivery of safe and high-quality care. TJC emphasizes patient safety, Infection Control, medication management, and other critical areas. While participation is voluntary,

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Management Communication – Task 2 7 many states use TJC accreditation as an indicator that a healthcare facility provides quality and safety of care and to qualify the facility to participate in programs such as Medicare and Medicaid (Safian, S. 2009). Another healthcare agency that influences noncompliance reporting is the Centers for Medicare and Medicaid Services (CMS). CMS is a federal agency that administers Medicare and Medicaid programs. It establishes regulations and standards that healthcare providers must follow to participate in these programs. CMS conducts audits and investigations to ensure compliance with regulations and can impose penalties or sanctions for noncompliance. A4. Reporting Coding Noncompliance The procedure for reporting coding noncompliance typically involves identifying the non-compliant coding through internal audits, coding reviews, or identification of discrepancies between documented patient information and assigned codes. Document the noncompliance coding including the specific coding errors or discrepancies identified. Notify the compliance officer or designated authority within the organization should be informed of the noncompliance. This can be done through a designated reporting channel or by following the organization’s established reporting procedures. The non- compliance must be investigated and addressed by the compliance officer or designated authority. This will involve reviewing medical records, consulting coding guidelines, and collaborating with coding staff or other relevant departments to determine the cause and extent of the noncompliance. Appropriate corrective measures should be implemented to prevent future noncompliance. Once a violation has been identified and connected to a specific employee, the disciplinary action policy should go into effect (Safian, S. 2009). Depending on the nature and severity of the noncompliance, reporting to external

Management Communication – Task 2 8 agencies or authorities may be required. This could involve reporting to the appropriate insurance provider, government agencies, or regulatory bodies. B1. Formal Request for Internal Audit When a healthcare organization receives a formal request for an audit by an internal reviewer, the organization should acknowledge the request for an audit, and provide all the necessary information related to coding claims, documentation, or providers' claims as requested by the internal reviewer. When auditors request information or documentation, healthcare providers should follow the HIPAA minimum necessary standard. This means cooperating with the auditor and providing only the requested information (Zellers & Talingting, 2023). The healthcare organization should cooperate and assist in the audit process by providing access to necessary systems, records, and staff members, and being available to answer questions or provide clarification during the audit process. Address any coding discrepancies or noncompliance identified by the internal reviewer. After a healthcare audit is complete, healthcare providers should review the audit findings and recommendations carefully and clearly communicate any corrective action plans to staff members so they’re aware of any policy updates (Zellers & Talingting, 2023). Internal audit serves as a proactive measure to identify any potential issues or areas of improvement within the organization. B2. Formal Request for External Audit When a healthcare organization receives a formal request for an audit by an external reviewer such as a government agency or a third-party auditor the organization should authenticate that the request is legitimate and credible. The healthcare organization should collaborate with the necessary departments, such as coding, billing, and compliance, to gather the requested information and ensure a

Management Communication – Task 2 9 comprehensive response. Healthcare organizations also help their medical coder get prepared because an external audit can be a stressful event. Coders need to understand the audit is not designed to tear down their work, rather it is a way to help the team develop and improve (Hcrsi, 2021). The healthcare organization should provide all requested documentation related to coding claims, documentation, and provider's claims. This may involve medical records, coding guidelines, policies, and any other relevant supporting documentation. The medical coding team will also need to prepare to give external auditors access to all the records they need and be ready to communicate with them (Hcrsi, 2021). The external audit is typically conducted by an independent entity to assess the accuracy of coding claims, documentation, or provider claims. It helps ensure compliance with regulatory requirements and identifies any potentially fraudulent activities or overbilling. B3. Overpayment If audit results show a coding practice resulting in an overpayment, a healthcare organization should thoroughly review the audit results to understand the specific coding practice that led to the overpayment. Determine the underlying cause for the coding practice resulting in an overpayment. This may involve investigating if it was due to a misunderstanding of coding guidelines, inadequate training, or intentional fraudulent activities. The healthcare organization should take immediate corrective actions to address the coding guidelines, providing additional training to staff, or updating policies and procedures. If it is required, the healthcare organization must refund the overpayment to the appropriate entity or payer. If the payer appeals for a refund on the call, the facility should insist on having a written record of the overpayment to avoid miscommunication in the future. After getting the

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Management Communication – Task 2 10 written request, assign a cheque to this request and send it to the insurance provider. If the address of the payer is unknown, then the cheque can be sent to the claims department with the subject ‘Attention: Overpayments’ on the envelope. This will demonstrate the organization’s commitment to ethical billing practices and compliance (Overpayment and Recovery in medical billing, n.d). Lastly, the healthcare organization must implement preventive measures to prevent future occurrences, establish procedures to ensure proper coding practices, regular internal audits, ongoing staff training, and a compliance program. C. Resources Hcrsi. (2021, November 16). Benefits of Medical Coding Audits & Why You Need one. Healthcare Resolution Services. https://healthcareresolutionservices.com/blog/benefits-of-medical-coding-audits- why-you-need-one/ Overpayment and recovery in medical billing: A comprehensive guide. Invensis. (n.d.). https://www.invensis.net/blog/overpayment-and-recovery-in-medical-billing#:~:text=Connect%20with %20the%20provider%20to,request%20to%20initiate%20a%20refund. Safian, S. (2009). Essentials of healthcare compliance. Delmar Cengage Learning. Zellers, A., & Talingting, V. (2023, April 12). The Healthcare Provider’s Guide to Accounting of Disclosures. ChartRequest. https://chartrequest.com/the-healthcare-providers-guide-to-accounting-of- disclosures/

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c807 task 2 use 4

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