In your response posts to at least two other peers’ initial posts, respond to the following: Compare and contrast your thoughts on the legal and compliance implications identified by you

Mary Jane Discussion:

Revenue Cycle Specialists ensure that there is integrity of the billing processes in accordance with compliance requirements. An organization has recruited an individual to fulfill this role, and newly collected data indicates that there is non-adherence to billing policy and procedures and the specialist is deviating from standard billing guidelines. The determination is made that there is fraudulent billing. 

Legal implications of fraudulent billing place the organization at risk for federal and state monetary penalties being levied. In addition to monetary penalties which can run very high based upon the number of billing fraud instances, there are also the organizational risk of being excluded from public health program (such as Medicare and Medicaid) participation. 

The organization should consider implementing a rapid improvement effort utilizing the services of a seasoned compliance expert (an internal or outsourced resource) to correct all the billing errors that have been discovered. Outside resources often have greater automated resources to code, clean, and validate the mid-level billing activities with accuracy. The organization should also consider evaluating the recruitment process for this specialized role and evaluate the onboarding training and competency validation. The individual involved may require performance counseling in addition to competency remediation. If the fraudulent billing were associated with reckless behaviors and the individual involved was still in their probationary period the organization might consider termination. If the root cause of the error is due to a training issue, the organization might consider implementing a competency focused on fraud, what it entails, and what best practices to avoid fraud are (Thaifur et al., 2021). Another recommendation to mitigate would be to incorporate the use of electronic platforms to assist in coding workflows. Computer assisted coding supports accuracy and efficiency (Casto & White, 2021, p. 183)

References

Casto, A., & White, S. (2021). Principles of healthcare reimbursement and revenue cycle management (7th ed.). American Health Information Management Association.

Thaifur, A. R., Maidin, M., Sidin, A., & Razak, A. (2021). How to detect healthcare fraud? “a systematic review”. Gaceta Sanitaria, 35, S441–S449.  https://doi.org/10.1016/j.gaceta.2021.07.022

Blake Discussion:

Billing compliance in healthcare can a challenging task, as medical billing is constantly changing and evolving as state and federal regulations, laws, and government assisted program like Medicare and Medicaid change and become more complexed. The billing specialist that was hired by a United States healthcare facility should fully comprehend that medical billing is critical for an organization finical stability (Danish, 2023). When it comes to financial compliance is to ensure that providers, services, and other practices are disseminated properly and ethically. When there is fraudulent billing that does not meet regulatory and contractual obligations, healthcare organizations can suffer drastic and costly consequences (Wolfson, 2020). Not only can non-compliance to policy and procedures set by organization be a financial strain, but can be harmful for the organizations reputation. When it comes to billing or services and compliance, it is essential that methods, policies, and adequate training is completed to reduce errors and fraudulent charges.

The acting manger and the hospital need to perform a full investigation. One of the best ways to gain insight of what happen is through a root-cause analysis (RCA). A RCA performed properly will highlight mistakes, provide an area to implement changes, can prevent reoccurrence of error happening again, and can overall improve financial stability for an organization (Scott, 2024). RCA cab provide insight of education flaws, computer or coding errors, challenges with electronic health records, or to see if the workloads are too much for staff.

Working together, the manager and the hospital can formulate an action plan to prevent these errors from occurring. Interventions include, but are not limited to creation and development of compliance program. This ensure that all employees are compliant with training and education, provides means to monitor and audit activities to identify issues, and set a standard process for all employees. A second intervention can include the use of advance technology programs and software to help with medical coding and billing. This may be upfront costs to the organization at first, but can be cost saving and/or even improve financial stability. Lastly, performing more routine audits and catching these prior to them reaching the patient can prove beneficial.

References

Danish, J. (2023, March 28). What is medical billing compliance? 5 ways to protect your practice – bryant legal group. Bryant Legal Group.  https://bryantlg.com/blog/what-is-medical-billing-compliance-and-5-ways-you-can-protect-your-practice/

Scott, S. (2024). Root out the cause of errors with rca. AAPC Knowledge Center.  https://www.aapc.com/blog/89904-root-out-the-cause-of-errors-with-rca/

Wolfson, J. (2020). What should health care organizations do to reduce billing fraud and abuse? Journal of Ethics | American Medical Association.  https://journalofethics.ama-assn.org/article/what-should-health-care-organizations-do-reduce-billing-fraud-and-abuse/2020-03

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