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Running Head: HIM 360 1
5-2 Final Project Milestone Two: Draft of Compliance and Recommendations
February 12,2022
I. Compliance
HIM 360 2
A compliance program refers to formalized effort in order to detect, prevent, and
respond to conduct the operation of a business that is inconsistent with state and federal laws
(Compliance program description - main line health, 2021). The importance of compliance
programs is that it ensures that the organizations adhere to the applicable state as well as
federal laws and other requirements of the healthcare sector. It helps in protecting practices
against abuse, waste, fraud, and other liability areas. One of the significant benefits of having
a formal compliance program is that it helps in establishing an organizational culture that
promotes detection, resolution, and prevention of conduct not conforming to the law or
ethical policies of the organization. Another prominent benefit is that it helps in reducing the
risk of improper or unlawful conduct. Not having a compliance program in place can result in
a number of disruptions in the delivery of patient care. It may even result in fines and other
legal consequences.
The formal compliance program that is in place has been carefully analyzed. It is
found that the compliance program meets all the requirements of the OIG specifications. It is
appropriate for the specific clinic type and meets the needs of the facility.
In case the compliance plan is not adhered to, it can result in a number of negative
consequences. It can affect the delivery of quality care to the patients in the healthcare
setting. Moreover, it may even give rise to several legal issues. In order to ensure optimum
compliance with the plan, the organization needs to monitor it carefully. For effective
monitoring, the goals can be broken down into a number of manageable steps. Then, the steps
can be monitored with the help of compliance staff, either from outside or inside the facility,
as per the requirement. A change that needs to be done in order to improve the usefulness of
HIM 360 3
the compliance program is to ensure that there is a dedicated person for each department.
This will help in lowering the chances of any confusion at the time of audit.
II. Recommendation
The quality of clinical coding is becoming increasingly important in the healthcare
setting (Jg et al., 1970). In order to enhance the coding process in the organization, there is a
need of making a number of adjustments. The staff members of the healthcare organization
must be provided with additional education to allow them to gain a better understanding of
the complete coding process. They need to be provided with sufficient information relating to
the coding guidelines. It also includes the HCPCS Level I and II. Moreover, they must also
be given education relating to documentation guidelines specific for E/M services as well as
NCCI PTP edits. It will help them in becoming more familiar with the coding process and
avoiding the chances of potential errors.
Another improvement in the clinical documentation processes is the application of
SNOMED CT. It is a suite of designated standards used in the US Federal Government
systems for clinical health information exchange (National Institutes of Health, 2021). It is a
comprehensive clinical healthcare terminology that enables meaning-based retrieval. The
system breaks down the terminology on the basis of procedures, diagnosis, symptoms, signs,
and causes of injury. It also has description tables that offer flexibility to express different
clinical concepts. With an effective coding program, it becomes easy to reduce errors and
enhance the accuracy of claims.
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In reference to quality measures, these improvements can result in more accurate
determination of a patient population through the tracking of procedural trends and diagnosis
on the basis of simple criteria such as gender, age, and more.
In order to meet the requirements of healthcare data reporting and to attain the
standards of the industry, it is important to provide the medical staff with appropriate
training. For effective training of medical staff, a refreshed presentation can be created. It will
ensure that all the staff members are well equipped with the basic tools in order to meet
compliance goals. All the staff members need to be properly certified. In case they are not
certified, they must be provided with the essential resources in order to ensure better
compliance. Chart audits can be conducted on a regular basis, and then the final report can be
submitted to the compliance committee. It will help in determining whether the medical staff
and healthcare providers require more education or not.
Fraud, as well as abuse, is frowned upon in the healthcare industry. Fraud can be
defined as the intentional misinterpretation of documentation that leads to unauthorized
payment or benefit. Some of the prominent examples of fraud are misrepresenting dates,
submitting claims of specific services that are not rendered, and misinterpretation of service
descriptions or duration. Accuse can be defined as the act performed beyond the acceptable
standards of medical necessity or professional conduct. In case the auditors suspect any kind
of abuse or fraud, it is important to document who has committed the fraud or abuse. In
addition, it is also essential to note when and where the fraud or abuse was committed. Other
important details need to be noted. If the auditors suspect any kind of abuse or fraud, they
need to report the authorities, such as the Department of Health and Human Services.
HIM 360 5
In order to improve the functions of the current process in the clinic, it is important to
implement the right technology. For this clinic, it is important to avail of an upgrade of the
technology. However, as the amount of errors is very small, it may not be required to change
the workflows. In terms of technology, a sandbox environment can be very beneficial. It is
especially beneficial for testing procedures and scenarios. This can provide the staff members
with a preview of kinks that must be worked out without causing any disruption to the current
workflow. The final product is implemented.
A number of additional resources may be required for the effective implementation of
the recommended technology. One of the important resources in training. Training sessions,
as well as webinars, need to be conducted before the implementation of the recommended
technology. It would be essential in order to ensure that all the staff members, as well as
healthcare providers, are able to properly understand the technology effectively. It also
provides them with an opportunity to ask their doubts and questions relating to the
technology and avail appropriate answers. It will enable them to gain insights into what they
can expect in the technology update. As the staff members get familiar with the system, it
will reduce their pressure of completing daily tasks in a timely manner. Another resource that
may be required is budget. The budget needs to be expanded. The healthcare organizations
may also consider grants in order to avail the required funding.
The audits are to be conducted on a regular basis. It should be done at an interval of
ninety days. However, in order to conduct the audits effectively, it is important to have a
proper schedule. It will help in conducting the audit in a systematic manner.
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After evaluation, there would not be a need to modify the workflow process in the
clinic, A technology update would be sufficient to get the desired outcomes.
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Compliance program description - main line health. (2021). Retrieved February 12, 2022,
from https://www.mainlinehealth.org/-/media/files/pdf/basic-content/about/policies/
Jg, K., Yitambe, A., & Go, O. (1970, January 1). [PDF] improving the quality of clinical
coding through the training of Health Records and information officers in selected
hospitals, Nairobi City County, Kenya: Semantic scholar. improving the quality of
clinical coding through the training of Health Records and information officers in
selected hospitals, Nairobi City County, Kenya: Semantic scholar. Retrieved February
12, 2022, from https://www.semanticscholar.org/paper/Improving-the-Quality-of-
National Institutes of Health. (2021). U.S. National Library of Medicine. Retrieved February
12, 2022, from https://www.nlm.nih.gov/healthit/snomedct/index.html
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