Case Study Module 10
docx
keyboard_arrow_up
School
Washington State Community College *
*We aren’t endorsed by this school
Course
1200
Subject
Medicine
Date
Dec 6, 2023
Type
docx
Pages
2
Uploaded by CorporalMoosePerson905
Case Study 15.1
David, a student from an accredited HIM program, was given a professional practice
experience project that required him to review reimbursement denials for Medicare
patients over the course of the past year. He noticed that the denials were higher when the
claim included services from the radiology department. He researched the claims and
resubmitted them with additional documentation. Through this process, he discovered that
the additional documents required were similar for each claim. Also, because of the settings
on the organization’s EHR, the required diagnosis codes for the radiological services
performed were not being submitted on the claim form, although the procedure code was
included on the claim. David communicated his findings to the manager, and they discussed
potential next steps.
1.What could cause a denial from an insurance company (3pts)?
A denial from an insurance company would be because of invalid or nonexistent ICD-10-Codes.
2.Outline suggestions for process improvement to help improve efficiency of the revenue
cycle management (3pts).
I think the health facility can update their EHRs to have the correct material needed for the
documentation of the procedures completed on the patients that the insurance companies require
to be able to approve the claims. I also think the health facility should also implement education
on the correct information that needs to be documented for the insurance for approval of the
claims.
3.Which departments are responsible for the revenue cycle problems at this company
(3pts)?
Case Study 15.2
Emily Kelley was taken to Kirklake Community Hospital for pain in her side. She was
admitted and taken into surgery, where her appendix was removed. In recovery her
temperature spiked, and after looking at Emily’s labs it was determined that she had
developed an infection from the surgery. This was not the first surgery where an infection
subsequently developed, and the current total HAC score for this hospital was 8. As a result
of the high HAC score, the reimbursement to the hospital for Emily’s surgery was less than
it should have been based on APC grouping. The billers noticed a decrease in
reimbursement and discussed it with the manager. The HIM manager approached the
performance improvement manager to discuss the spike in HACs. She was able to provide
the data to support an investigation into why this was happening. It was determined that
the infections were occurring when a particular provider was on staff.
1.Why would the reimbursement rate decrease for this hospital (3pts)?
The reimbursement rate would decrease for this hospital because their HAC scores are high.
2.What should the hospital do to determine why the infection rates are high (3pts)?
The hospital should monitor who and what infections the patients are getting from surgery then
they should establish why they are getting them.
3.What can patients do if they have choices of where to go for their care (3pts)?
Patients can choose to be transferred to a different hospital to receive their care. They have the
right to refuse treatment and leave or they have the right to be transferred to a different facility.
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help