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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 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. aa
B.
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.
C.
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
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outside or inside the facility, as per the requirement. A change that needs to be done in
order 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.
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.
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 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.
C.
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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.
D.
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.
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.
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F.
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.
G.
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.
H.
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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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.
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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
