Summary
As the newly appointed Chief Financial Officer (CFO) at the hospital, one essential responsibility is ensuring the institution’s compliance with regulations. Among common issues clinics might face are complaints, which can lead to legal reviews of violations and jeopardize the hospital’s reputation. Therefore, the focus in the hospital should be on integrating a system of checks and balances, conducting periodic audits, providing staff training, and performing charge reconciliation, which, when combined, will help reduce the risks of violations and complaints.
Diagnostic and Billing Frameworks
The first aspect to consider is the concepts of diagnosis, classification, care reimbursement, and the billing system used in the hospital. In the case of the diagnosis classification, the International Classification of Diseases (ICD) is commonly applied. This framework enables the hospital to utilize globally recognized knowledge and data regarding human definitions of diseases and injuries, procedures, and diagnoses (Niles, 2019).
Another element, care reimbursement, is critical in the hospital. On the one hand, CMS is used by the government to reimburse hospitals for patient bills based on Medicaid and Medicare insurance (Niles, 2019). On the other hand, private insurance companies’ reimbursement services are used based on negotiated contracts (Niles, 2019). Finally, the billing system is based on billing collection, processes, and coding.
Patient Needs and Service Expectations
Meeting the patients’ needs, priorities, and expectations is another essential aspect. It is essential to incorporate several policies to ensure that all patients’ requirements are satisfied in a manner that exemplifies the values of respect, compassion, justice, and community pride. Among the required policies are those addressing transparency in billing and financial matters, clear communication, and the provision of quality care to patients. This way, reducing the number of complaints and boosting the clients’ satisfaction will be possible.
Common Coding and Billing Violations
In terms of violations, the ones concerning upcoding, duplicated charges, phantom charges, unbundling, and incorrect quantities are to be considered. The first violation, upcoding, involves charging more for a higher level of service that was not provided (Niles, 2019). This issue can be eliminated by incorporating a system of checks and balances to help monitor the services provided.
The following violations, including duplicated and phantom charges, suggest that a service was charged more than once or that a client was charged for a service not provided (Niles, 2019). In this situation, periodic audits and charge reconciliations can be implemented, which would help maintain operational accuracy. Then, unbundling is based on billing the person for services that should be charged together (Niles, 2019). In such a case, staff should be provided with proper training on the billing system to avoid mistakes.
Finally, incorrect quantities refer to billing for more units of services that were not provided (Niles, 2019). Similar to the first outlined solution, a system of checks and balances will be needed.
Contingency Plan and Corrective Measures
Lastly, when discussing the contingency plan, it is necessary to reiterate the offered solutions to address the violations. To minimize risks and maintain seamless hospital operations, it is essential to implement checks and balances, conduct regular audits, and reconcile charges. Additionally, it will be essential to provide employees with training on the billing system. Combined, these actions will help mitigate the crisis and avoid such mistakes.
The drills will help the hospital better prepare for future crises by assessing the staff’s reactions and actions. Moreover, when considering staff, the crisis can affect them in a way that decreases their productivity and increases stress. To mitigate this risk, it is essential to introduce regular meetings where employees can share their thoughts in a comfortable environment and express their concerns and demands.
Reference
Niles, N. J. (2019). Basics of the U.S. health care system. Jones & Bartlett Learning, LLC.