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5-2 Final Project Milestone Two: Draft of Compliance and Recommendations
HIM360
SNHU
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I. Compliance
A.
A compliance program refers to formalized effort 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 several disruptions in the delivery of patient care. It may even result in fines and
other legal consequences. n
B.
The formal compliance program that is in place has been carefully analysed. 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.
C.
In case the compliance plan is not adhered to, it can result in several 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. To ensure optimum compliance with the plan, the organization
needs to monitor it carefully. For effective monitoring, the goals can be broken down into several
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 to improve the
usefulness of 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
A.
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The quality of clinical coding is becoming increasingly important in the healthcare setting (Jg
et al., 1970). 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.
B.
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 based on 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.
C.
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 based
on simple criteria such as gender, age, and more.
D.
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 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 to
ensure better compliance. Chart audits can be conducted on a regular basis, and then the final report
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can be submitted to the compliance committee. It will help in determining whether the medical staff
and healthcare providers require more education or not.
E.
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.
F.
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 number 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.
G.
Several 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 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
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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 to avail the required funding.
H.
The audits are to be conducted on a regular basis. It should be done at an interval of ninety
days. However, to conduct the audits effectively, it is important to have a proper schedule. It will help
in conducting the audit in a systematic manner.
I.
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.
References
Compliance program description - main line health. (2021). Retrieved February 12, 2022, from
https://www.mainlinehealth.org/-/media/files/pdf/basic-content/about/policies/compliance-
program-description.pdf?la=en
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-Clinical-Coding-through-of-
Jg-Yitambe/a0359b62da070dcfe0bfa43c109c36186374349c
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
