Professional fee billing Compliance plan

1
MRC145
–
Coding Compliance & Ethics
Portfolio Project Directions and Rubric
This Assessment is worth 20% of your overall grade
Outcomes
Completing this Assessment will help you to:
Course Outcomes
•
Learn the key terms related to medical compliance.
•
Differentiate between myth and fact regarding medical compliance.
•
Analyze the components of a voluntary compliance program, including the benefits and shortfalls
of implementation.
•
Differentiate among laws, regulations, and policies in the medical complian
ce arena.
Program Outcomes
•
Demonstrate a professional
–
level understanding of medical terminology, anatomy and physiology,
pathophysiology and pharmacology.
•
Create a medical practice compliance plan based on national standards, and have a thorough
understan
ding of coding, documentation, and reimbursement ethics.
•
Assign CPT codes to medical documentation for medical services, procedures, and diagnostics.
•
Correctly assign CPT E/M codes to services, utilizing the CPT metrics, including the 1995 and
1997 CMS Doc
umentation Guidelines.
•
Correctly assign HCPCS codes to durable medical equipment, drugs, supplies, and Medicare
screening services, according to CMS guidelines.
•
Assign current diagnosis codes, according to the American Hospital Association’s standards and
sequencing rules, for inpatient and outpatient medical services.
•
Assign current procedure codes, according to the American Hospital Association’s standards and
sequencing rules, for inpatient services
Institutional Outcomes
•
Information Literacy and Communi
cation
–
Please demonstrate how you utilized appropriate
current technology and resources to locate and evaluate information needed to accomplish a
goal, and then illustrate how you communicated your findings in visual, written, and/or oral
formats.
•
Relati
onal Learning
–
Provide an example and discuss the ways in which you were able to
transfer knowledge, skills, and behaviors acquired through formal and informal learning, and life
experiences to new situations.
•
Thinking Abilities
–
Please provide an examp
le of how you employed strategies for reflection on
learning and practice. How did you utilize this process in order to adjust your learning process for
continual improvement?
•
Quantitative and Scientific Reasoning
–
Provide an example and discuss the ways
in which
you followed established methods of inquiry and mathematical reasoning to form conclusions and
make decisions.
•
Community and Career
–
Provide an example through which you were able to participate in
social, learning, and professional communities f
or personal and career growth. Evaluate your
participation and what you learned from your involve.
Deadline
Deliverable items for the Portfolio Project will be required at different points during our
course. The timeline is as follows:
Assignment for
Submission
Assignment Due Date
Grading Scale
Submit
Portfolio Project
Rough Draft
.
Week 5 by Saturday at 11:59
pm, ET.
Submission will be worth 5%
of your overall Portfolio
Project grade.
Upload Portfolio Project to
your
eP
ortfolio
.
Upload Portfolio
Project Reflection
Week 7
by Saturday
at 11:59
pm, ET.
Submission will be worth
15% of your overall Portfolio
Project grade.
MRC145
–
Portfolio Project
2
Brief Overview of Healthcare Compliance
After the passage of the Health Insurance Portability and Accountability Act of 1996
(HIPAA), many companies in the healthcare industry developed corporate compliance
programs. HIPAA gives the U.S. Department of Health and Human Service’s Office of
Inspector General and the U.S. Department of Justice more investigational funding and
autho
rity to increase penalties for healthcare fraud and abuse. Meanwhile, the
government searches for violations of the 2006 False Claims Act and other federal laws
.
In order to protect themselves, healthcare organizations must implement compliance
programs as
outlined in the U.S. Sentencing Guidelines. If an organization is found to
violate federal criminal laws, but the organization’s compliance program satisfies the
guidelines, assessed penalties may be reduced up to 70%
.
Understanding the components of hea
lthcare compliance and being able to formulate
an original compliance plan will help prospective medical billers and coders to prepare
for the CPC or the AHIMA certifications.
For more on healthcare compliance programs,
visit the website of the
Health Care Compliance Association
.
Scenario
Sarah Cobb, the CEO of North Side Medical Corporation, has a real dilemma on her
hands. An unexpected audit by the Joint Commission of Accreditation for Hospital
Orga
nizations (JCAHO) found the corporation’s compliance programs to be outdated.
Most of the errors are minor and can be corrected immediately. But others are
significant and will require time and resources to amend. Specifically, the billing aspect
of the
compliance plan must be updated. Otherwise, the corporation could lose its
accreditation and would no longer be permitted to treat patients who are insured
through Medicare or Medicaid. This would cost North Side millions of dollars and put
the corporati
on on a path to bankruptcy. North Side’s hospital has 30 days to develop
and implement a new professional fee
–
billing compliance plan.
Directions
You have been hired to
:
(1) develop a new compliance program for the corporation and
(2) establish requireme
nts that would be used in hiring a new company to do the billing.
To
comply with JCAHO’s requirements,
your professional fee
–
billing program must
include the following
organization and criteria
:
•
Introduction
o
Provides an overview of a professional
fee
–
billing progr
am.
o
Describes plan and includes additional background information.
o
Choice of billing company
.
Justify your reasoning for the company.

Professional fee billing Compliance plan

1
MRC145
–
Coding Compliance & Ethics
Portfolio Project Directions and Rubric
This Assessment is worth 20% of your overall grade
Outcomes
Completing this Assessment will help you to:
Course Outcomes
•
Learn the key terms related to medical compliance.
•
Differentiate between myth and fact regarding medical compliance.
•
Analyze the components of a voluntary compliance program, including the benefits and shortfalls
of implementation.
•
Differentiate among laws, regulations, and policies in the medical complian
ce arena.
Program Outcomes
•
Demonstrate a professional
–
level understanding of medical terminology, anatomy and physiology,
pathophysiology and pharmacology.
•
Create a medical practice compliance plan based on national standards, and have a thorough
understan
ding of coding, documentation, and reimbursement ethics.
•
Assign CPT codes to medical documentation for medical services, procedures, and diagnostics.
•
Correctly assign CPT E/M codes to services, utilizing the CPT metrics, including the 1995 and
1997 CMS Doc
umentation Guidelines.
•
Correctly assign HCPCS codes to durable medical equipment, drugs, supplies, and Medicare
screening services, according to CMS guidelines.
•
Assign current diagnosis codes, according to the American Hospital Association’s standards and
sequencing rules, for inpatient and outpatient medical services.
•
Assign current procedure codes, according to the American Hospital Association’s standards and
sequencing rules, for inpatient services
Institutional Outcomes
•
Information Literacy and Communi
cation
–
Please demonstrate how you utilized appropriate
current technology and resources to locate and evaluate information needed to accomplish a
goal, and then illustrate how you communicated your findings in visual, written, and/or oral
formats.
•
Relati
onal Learning
–
Provide an example and discuss the ways in which you were able to
transfer knowledge, skills, and behaviors acquired through formal and informal learning, and life
experiences to new situations.
•
Thinking Abilities
–
Please provide an examp
le of how you employed strategies for reflection on
learning and practice. How did you utilize this process in order to adjust your learning process for
continual improvement?
•
Quantitative and Scientific Reasoning
–
Provide an example and discuss the ways
in which
you followed established methods of inquiry and mathematical reasoning to form conclusions and
make decisions.
•
Community and Career
–
Provide an example through which you were able to participate in
social, learning, and professional communities f
or personal and career growth. Evaluate your
participation and what you learned from your involve.
Deadline
Deliverable items for the Portfolio Project will be required at different points during our
course. The timeline is as follows:
Assignment for
Submission
Assignment Due Date
Grading Scale
Submit
Portfolio Project
Rough Draft
.
Week 5 by Saturday at 11:59
pm, ET.
Submission will be worth 5%
of your overall Portfolio
Project grade.
Upload Portfolio Project to
your
eP
ortfolio
.
Upload Portfolio
Project Reflection
Week 7
by Saturday
at 11:59
pm, ET.
Submission will be worth
15% of your overall Portfolio
Project grade.
MRC145
–
Portfolio Project
2
Brief Overview of Healthcare Compliance
After the passage of the Health Insurance Portability and Accountability Act of 1996
(HIPAA), many companies in the healthcare industry developed corporate compliance
programs. HIPAA gives the U.S. Department of Health and Human Service’s Office of
Inspector General and the U.S. Department of Justice more investigational funding and
autho
rity to increase penalties for healthcare fraud and abuse. Meanwhile, the
government searches for violations of the 2006 False Claims Act and other federal laws
.
In order to protect themselves, healthcare organizations must implement compliance
programs as
outlined in the U.S. Sentencing Guidelines. If an organization is found to
violate federal criminal laws, but the organization’s compliance program satisfies the
guidelines, assessed penalties may be reduced up to 70%
.
Understanding the components of hea
lthcare compliance and being able to formulate
an original compliance plan will help prospective medical billers and coders to prepare
for the CPC or the AHIMA certifications.
For more on healthcare compliance programs,
visit the website of the
Health Care Compliance Association
.
Scenario
Sarah Cobb, the CEO of North Side Medical Corporation, has a real dilemma on her
hands. An unexpected audit by the Joint Commission of Accreditation for Hospital
Orga
nizations (JCAHO) found the corporation’s compliance programs to be outdated.
Most of the errors are minor and can be corrected immediately. But others are
significant and will require time and resources to amend. Specifically, the billing aspect
of the
compliance plan must be updated. Otherwise, the corporation could lose its
accreditation and would no longer be permitted to treat patients who are insured
through Medicare or Medicaid. This would cost North Side millions of dollars and put
the corporati
on on a path to bankruptcy. North Side’s hospital has 30 days to develop
and implement a new professional fee
–
billing compliance plan.
Directions
You have been hired to
:
(1) develop a new compliance program for the corporation and
(2) establish requireme
nts that would be used in hiring a new company to do the billing.
To
comply with JCAHO’s requirements,
your professional fee
–
billing program must
include the following
organization and criteria
:
•
Introduction
o
Provides an overview of a professional
fee
–
billing progr
am.
o
Describes plan and includes additional background information.
o
Choice of billing company
.
Justify your reasoning for the company.

Professional fee billing Compliance plan

1
MRC145
–
Coding Compliance & Ethics
Portfolio Project Directions and Rubric
This Assessment is worth 20% of your overall grade
Outcomes
Completing this Assessment will help you to:
Course Outcomes
•
Learn the key terms related to medical compliance.
•
Differentiate between myth and fact regarding medical compliance.
•
Analyze the components of a voluntary compliance program, including the benefits and shortfalls
of implementation.
•
Differentiate among laws, regulations, and policies in the medical complian
ce arena.
Program Outcomes
•
Demonstrate a professional
–
level understanding of medical terminology, anatomy and physiology,
pathophysiology and pharmacology.
•
Create a medical practice compliance plan based on national standards, and have a thorough
understan
ding of coding, documentation, and reimbursement ethics.
•
Assign CPT codes to medical documentation for medical services, procedures, and diagnostics.
•
Correctly assign CPT E/M codes to services, utilizing the CPT metrics, including the 1995 and
1997 CMS Doc
umentation Guidelines.
•
Correctly assign HCPCS codes to durable medical equipment, drugs, supplies, and Medicare
screening services, according to CMS guidelines.
•
Assign current diagnosis codes, according to the American Hospital Association’s standards and
sequencing rules, for inpatient and outpatient medical services.
•
Assign current procedure codes, according to the American Hospital Association’s standards and
sequencing rules, for inpatient services
Institutional Outcomes
•
Information Literacy and Communi
cation
–
Please demonstrate how you utilized appropriate
current technology and resources to locate and evaluate information needed to accomplish a
goal, and then illustrate how you communicated your findings in visual, written, and/or oral
formats.
•
Relati
onal Learning
–
Provide an example and discuss the ways in which you were able to
transfer knowledge, skills, and behaviors acquired through formal and informal learning, and life
experiences to new situations.
•
Thinking Abilities
–
Please provide an examp
le of how you employed strategies for reflection on
learning and practice. How did you utilize this process in order to adjust your learning process for
continual improvement?
•
Quantitative and Scientific Reasoning
–
Provide an example and discuss the ways
in which
you followed established methods of inquiry and mathematical reasoning to form conclusions and
make decisions.
•
Community and Career
–
Provide an example through which you were able to participate in
social, learning, and professional communities f
or personal and career growth. Evaluate your
participation and what you learned from your involve.
Deadline
Deliverable items for the Portfolio Project will be required at different points during our
course. The timeline is as follows:
Assignment for
Submission
Assignment Due Date
Grading Scale
Submit
Portfolio Project
Rough Draft
.
Week 5 by Saturday at 11:59
pm, ET.
Submission will be worth 5%
of your overall Portfolio
Project grade.
Upload Portfolio Project to
your
eP
ortfolio
.
Upload Portfolio
Project Reflection
Week 7
by Saturday
at 11:59
pm, ET.
Submission will be worth
15% of your overall Portfolio
Project grade.
MRC145
–
Portfolio Project
2
Brief Overview of Healthcare Compliance
After the passage of the Health Insurance Portability and Accountability Act of 1996
(HIPAA), many companies in the healthcare industry developed corporate compliance
programs. HIPAA gives the U.S. Department of Health and Human Service’s Office of
Inspector General and the U.S. Department of Justice more investigational funding and
autho
rity to increase penalties for healthcare fraud and abuse. Meanwhile, the
government searches for violations of the 2006 False Claims Act and other federal laws
.
In order to protect themselves, healthcare organizations must implement compliance
programs as
outlined in the U.S. Sentencing Guidelines. If an organization is found to
violate federal criminal laws, but the organization’s compliance program satisfies the
guidelines, assessed penalties may be reduced up to 70%
.
Understanding the components of hea
lthcare compliance and being able to formulate
an original compliance plan will help prospective medical billers and coders to prepare
for the CPC or the AHIMA certifications.
For more on healthcare compliance programs,
visit the website of the
Health Care Compliance Association
.
Scenario
Sarah Cobb, the CEO of North Side Medical Corporation, has a real dilemma on her
hands. An unexpected audit by the Joint Commission of Accreditation for Hospital
Orga
nizations (JCAHO) found the corporation’s compliance programs to be outdated.
Most of the errors are minor and can be corrected immediately. But others are
significant and will require time and resources to amend. Specifically, the billing aspect
of the
compliance plan must be updated. Otherwise, the corporation could lose its
accreditation and would no longer be permitted to treat patients who are insured
through Medicare or Medicaid. This would cost North Side millions of dollars and put
the corporati
on on a path to bankruptcy. North Side’s hospital has 30 days to develop
and implement a new professional fee
–
billing compliance plan.
Directions
You have been hired to
:
(1) develop a new compliance program for the corporation and
(2) establish requireme
nts that would be used in hiring a new company to do the billing.
To
comply with JCAHO’s requirements,
your professional fee
–
billing program must
include the following
organization and criteria
:
•
Introduction
o
Provides an overview of a professional
fee
–
billing progr
am.
o
Describes plan and includes additional background information.
o
Choice of billing company
.
Justify your reasoning for the company.