Discussion Reply- Response 1-2 paragraphs with 1-2 references

Liliana Brisson

Billing Fraud and Abuse

Internal audits done periodically are key to the success of a healthcare organization and help identify discrepancies that could be avoided or should be addressed. This also helps prepare an organization for possible larger audits like the Medicare Fee for Service Recovery Audit Program (RAC). A billing specialist acts as a liaison between the hospital/practice and insurance companies and must comply with billing policies and procedures, and coding to ensure proper reimbursement. However, in this situation the billing specialist is not following the standard billing guidelines, has billing errors, and noncompliance with the hospital’s standard process in several patient bills. As a manager, it is important to identify and know the legal and compliance implications of the billing specialist actions. Not adhering to billing guidelines, noncompliance, and billing errors, fall under the Medicare Laws and Abuse Laws. “When you submit a claim for services provided to a Medicare beneficiary, you are filing a bill with the Federal government and certifying you earned the payment requested and complied with the billing requirements. If you knew or should have known the submitted claim was false, then the attempt to collect payment is illegal” (Cms.gov., 2022).

Our hospital should respond to this issue by letting go of our current billing specialist and identifying the billing and noncompliance errors, which could be challenging. Once identified, the hospital should then try to appeal the claims if possible and if eligible for appeal. However, in a lot of cases patient billing errors may not be appealed, are written off, and taken as a monetary loss. By highlighting those errors, they can be reviewed and revised when training staff, physicians, and billing personnel in the future. “A claim found to be unpayable by the insurance company is a denied claim, usually due to billing errors, omitted information, or patient coverage. In some instances, denied claims are eligible for appeal and reprocessing. A claim with incorrect patient or insurance information or other errors can be declined, which is a rejected claim. These claims are never entered into the payer’s computer system. When the error is corrected, the claim will have to be resubmitted” (Hughes, 2019). Learning where and why errors occurred will benefit the hospital by making sure they are more systematic with future payments and billing.

Measures the hospital should take to prevent the recurrence of this issue is dividing the billing and coding system into two dedicated and specialized employees. One in charge of billing and one in charge of coding. Having an appropriate up-to-date software system in place will help decrease some errors. Continued internal audits will be necessary to make sure that errors are not occurring on the daily basis. CMS programs through the office of inspector general (OIG) provide resources for medical professionals that help prevent errors. Every hospital employee that has anything to do with billing should go through these sources for training, and additional one-on-one training should be provided. “To help healthcare providers such as hospitals and physicians comply with relevant Federal health care laws and regulations, OIG creates compliance resources, which are often tailored to particular providers. OIG's compliance documents include special fraud alerts, advisory bulletins, podcasts, videos, brochures, and papers providing guidance on compliance with Federal health care program standards” (Cms.gov., 2022). In addition, looking at the CMS and RAC webpage for any coding changes or resources will be beneficial.

References:

Cms.gov. 2022. [online] Available at: <https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud-Abuse-MLN4649244-Print-Friendly.pdf> [Accessed 15 January 2022].

Hughes, S., 2019. 5 Common Medical Billing Errors | Coronis. [online] Coronis. Available at: <https://www.coronishealth.com/blog/5-common-medical-billing-errors/> [Accessed 15 January 2022].

2022. [online] Available at: <https://oig.hhs.gov/compliance/> [Accessed 15 January 2022].