Evaluating Compliance Strategies, Essay Example

The medical records at a hospital contain a great deal of Patient / Doctor confidential information.  This contains such items as demographic information on the patient, summary medical history, reports from the physician and other specialists etc.  The payment process for the patient is most often made by the completion of medical insurance information.  Historically this has posed an administrative burden on the Hospitals.

Figure 1 : Medical Billing Process at O21

A great deal of this administrative work in terms of data collection, retention of billing and coding compliance is being outsourced.  Fig 1 shows an  example flow chart of the billing process as   produced by the Indian for the O21.  India has become a favorite option for outsourcing owing  to the significant industry experience, accuracy and quality results and  a high level of security . ” Medical billing service providers have familiarized themselves with US medical billing industry practices. With adequate training and knowledge sharing mechanisms in place, medical billing companies in India ensure that each staff member has access to vast knowledge repositories on the latest in the medical billing domain. Ongoing program development and implementation significantly reduce the risk of inappropriate medical billing practices and unlawful billing techniques” (O2I, 2009).

Historically there has been somewhat of a disconnect between the Doctors who are at the sharp end of the medical practice and the back office administrative function.  This has often placed the Doctors at a disadvantage..” Many physicians rely on office staff and billing companies to process their medical bills without ever reviewing the bills before they are submitted for payment. Some physicians may not be receiving the payment they deserve when they do not sufficiently oversee the medical practice’s coding and billing patterns.” (Diane L. Adams, 2002).

In an overworked administrative hospital department, then, the concept of outsourcing this to specialist service providers is an optimum strategy.  From this perspective it would lead the administrative department to focus more on control and audit compliance of the function whilst alleviating it of the problem of the day to day routine work. ” the importance of monitoring and auditing medical record documentation and coding application as a strategy for achieving compliance and reducing billing errors. When medical bills are submitted with missing and incorrect information, they may result in unpaid claims and loss of revenue to physicians.” (Diane L. Adams, 2002).

It is important to link the procedures with the diagnostic codes, because these will be used in order to determine the cost of the treatment for appropriate billing and medical insurance claims.  The coach also play an important role in the hospital quality assurance methods.  [PQRI] and the concept of supporting medical necessity.  Such codes are also used in audit procedures when examining consistency of medical practice and the quality attributable to patient care.  Incorrect medical billing has the potential to cause the hospital’ and result in erroneous insurance claims. ” Today’s complex medical billing and hospital billing system allows fraud and abuse to go undetected. Studies have shown that as many as 9 out of 10 medical bills and hospital bills contain errors (of course, always overcharging you). Hospital bill errors and doctor bill errors are compounded by the fact that insurance companies are not reimbursing correctly–they just pay the incorrect medical bills unquestioningly, but deny legitimate charges.” (Hurt 911, 2010)

The compliance process needs to record the exact medical procedures that were carried out by the doctors and nursing staff.  This inter  relates to precise medical codes that tie into the billing process.  Leading  to the ability to transcribe these to the insurer  records or forms that have to be completed for insurance payer reimbursement.  One of the biggest complaints by the insurers is that the doctor’s reports are incomplete and that they are not referring to the medical manuals for completion of the requisite coding. This in turn leads to a level of inaccuracy in the process.  The counterargument to this being the Doctors do not have sufficient time to deal with these administrative procedures, owing to the amount of demand made upon them in dealing with more important medical procedures.  Nevertheless, the hospital is still being run as a business or on business lines and as such, cannot afford bad administrative practices that potentially may put the hospital into a loss making situation.

The obvious situation would seem the need to incorporate a strategy that empowers the Doctors.  An example of this might be the incorporation  of technology into the administrative process i.e., the issue of tablet computers to the Doctors , whereby they enter the coded information directly into a handheld computers  at the time of treatment.  The actual data can then be manipulated by the back-office staff.  In ideal terms this supports the concept  of the outsourcing situation where you equally empower the administrators of the hospital.  This being In more of a control and audit situation over the outsourced firm managing the billing and coding procedure.

Works Cited

Diane L. Adams, H. N. (2002). Addressing medical coding and billing part II: a strategy for achieving compliance. A risk management approach for reducing coding and billing errors. Journal of the National Medical Association , 430–447. .

Hurt 911. (2010). Medical Billing Errors & Hospital Billing Errors. Retrieved 5 10, 2010, from Hurt 911: http://www.hurt911.org/medical/medical-bill-error-hospital-bill-error-medical-insurance.html

O2I. (2009). Medical Billing Process at Outsource2india. Retrieved 5 10, 2010, from O2I: http://www.outsource2india.com/services/medical_billing_process.asp