Medical billing and Coding Essay
Medical billing and Coding
Medical coding is the translation of writing such as a diagnostic into a code as each injury, medicine, the diagnosis has a code (Medical Billing & Coding Certification, n.d.). Medical billing o the other hand is using information gotten through medical coding and using it to make a claim in the insurance company by presenting a bill (American Health Information Management Association, n.d.). There several fraud/abuses of medical billing and coding that can occur. An example is billing for services that have not been performed. So as to not encounter such frauds in the hospital, the organization usually sets up policies and procedures to prevent this from happening.
The first example of abuse is billing for services not performed. So as to charge the insurance company or the patient more, the billing and coding department can add some services not rendered as part of the bill. This adds to the money that they are going to claim. This sometimes works perfectly for those people who are being covered by insurance and don’t bother to look at what is being charged for thus the billing department is able to get away with this. In the coding department, there might be a falsification of medical records i.e. the codes used and the treatment offered. This occurs when different codes are used other than the right codes. This may result in higher payments being billed. The third form of abuse that mostly occurs in the billing departments is the alteration of claim forms to ask for higher payments (American Health Information Management Association, n.d.). The amount being billed may be less than the amount being paid hence being a fraud.
One of the procedures used when this happens is that there is no retaliation against the victim or rather party affected for reporting a violation. Discrimination against them can easily take place thus this procedure would be very helpful in protecting them. a policy put in place to prevent alteration of claims is that the health department is committed to providing true and accurate claims for payments and provides training for the submission process. This policy is effective as it prevents the billing team from making any mistakes when it comes to coming up with a claim. Another policy is to continuously review the policies and procedures that concern billing. This is a very effective policy as it ensures that the policies are up to date with the current fraud trends ensuring there are no loopholes.
Employee Orientation Program
The new orientation program is created to guide the employees in what they are supposed to do. It is implemented so as to offer new employees training on their ne tasks and ensure that they know what is expected of them. The evaluation measures the success rate of the program.
|Description||Objectives||Learning Activities||Date of Completion|
|Facility Tour||Ensure that the new employees have seen all the departments.||The departments in the facility and their roles|
|Introduction to co-workers||Knowing their potential colleagues and team leaders||They will learn who to go to when they have a problem in their line of work|
|Reviewing of the Employee Handbook||Review the regulations put in place for the facility to run smoothly.Allow them to understand what is required of them by the facility.Understanding the dos and don’ts of the facility.||The employees will understand the regulations and polices put in place and understand what to do when faced with certain situations.|
|Evaluation of the employees’ knowledge on the frauds and abuses that can occur in the facility.||Test their knowledge on frauds and abuses that can take place||They will learn different types of frauds and abuse that can take place in the facility.|
|Training program||They will take part in the training program put in place for each department||Learn the do’s and don’ts in the specific departments.|
|Evaluation||Evaluation on what they have learned in the training program.||Anything not clear to them from the training program will be clarified.|
|Signing of Contracts||The new employees will sign their contracts||This part makes them part of the team officially.|
Training Program for the medical billing ad coding team
This program will be put in place for the medical billing and coding department mostly to ensure that the employees are aware of what is expected of them.
|Description||Learning Objectives||Date of Completion|
|Review of the employees’ goals and job description||Ensuring that the employees know what is expected of them.Ensuring that the employees know the goals of their jobs|
|Review of rules and regulations||Ensure that the employees know the rules and regulations that they are supposed to follow.|
|Teach them on decision-making skills||Teaching them decision making skills helps the employees learn how to make the right decisions to avoid any mistakes due to poor judgment.|
|Update them on the current frauds/abuse trends||This is to let the employees know of activities that can be termed as illegal in the facility.|
|Update them on any new policies put in place||To ensure that the employees are up-to-date, they must be taught of the new policies that have been put into place.|
|Train them on how to handle certain situations if they come across them.||This gives the employees understanding on how to handle certain types of situations.|
|Evaluation||Evaluate whether the employees have taken in what has been taught to them.|
The leadership approach taken would be to ensure that all the employees are up to the task. Failing of the evaluation test would lead to attending the training program again. The programs should always be up-to-date with current trends.
Evaluation plan for the programs
The first step is to identify the participants taking part in the program. For the new orientation program, the participants are the potential employees that have already been vetted and for the training program, the participants would be people in the department of medical billing and coding. There is need to also identify what is being measured, in this case, the new orientation program is mostly testing if the new potential employees are up to the tasks ahead. The training program is to evaluate if the employees are up to date with the current policies.
The next step is to ensure that the programs fit the job requirements of the participants. This can be seen by objectives such as reviewing the employee handbook for the orientation program and updating the employees of new policies for the training program. Afterward, the performance of the evaluation tests taken by the participants at the end of the program should be an indication of whether the programs were a success. The target performance goal and the actual performance goal realized should be in close approximation. Follow-up evaluations in periodic time would also be necessary for ensuring whatever was taught to the employees has stuck and that the programs were successful.
To deliver quality patient care, a data warehouse in a health care organization must be used even though it can be time-consuming (Sahama & Croll, 2007). A challenging task in the architecture of a healthcare data warehouse is the integration of clinical data. A data warehouse in a health care organization is important as it gives an efficient way to analyze accumulated data to help the management in making strategic decisions. Through data warehousing, massive amounts of data from different sections of the organizations can be integrated and presented simplistically. An enterprise data warehouse allows the integration of data from multiple sources. The data warehouse is subject-oriented meaning that all the information about a certain subject is stored in one storage location. It is non-volatile meaning that the data doesn’t keep changing. The data warehouse is time-variant which means that the current and historic information of a subject is all present.
The benefits of an EDW include the ability to integrate data from multiple sources as discussed above. The enterprise data warehouse offers patients information safety as only authorized people can access the data. Another benefit is that the management can monitor a subject efficiently, for example, they can monitor the use of a certain drug ensuring that it is meaning used appropriately.
A strategic objective for the healthcare organization is to ensure easier access to records of a subject for example a patient or a drug by authorized personnel only. This can be facilitated through a data warehouse through the integration of data from multiple sources and the security features of the data warehouse. This allows only the authorized personnel to have access to the records and it is easier due to integration. The data warehouse also supports confidentiality which is highly required in the organization.
Clinical automation systems can be used in the entry of medical records in multiple sources allowing the retrieval to be easier and faster. The entered records are stored in a data warehouse where they can be easily accessed with ease. The automation systems also ensure that the retrieval of data is only done by authorized access by ensuring that the records are entered correctly in the correct storage location. Personal health records are stored in the data warehouse ensuring only authorized persons can access them. The personal health records ensure confidentiality between the patient and the authorized person (Stolba, Banek, & Tjoa).
American Health Information Management Association. (n.d.). Healthcare Fraud and Abuse. Retrieved from NCBI-NIH: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2804462/#:~:text=Some%20of%20the%20most%20common,such%20as%20International%20Classification%20of
Medical Billing & Coding Certification. (n.d.). What is Medical Billing and Coding? Retrieved from Medical Billing & Coding Certification: https://www.medicalbillingandcoding.org/medical-billing-coding/
Sahama, T. R., & Croll, p. R. (2007, January). A Data Warehouse Architecture for Clinical Data Warehousing. Retrieved from ResearchGate: https://www.researchgate.net/publication/27473559_A_Data_Warehouse_Architecture_for_Clinical_Data_Warehousing
Stolba, N., Banek, M., & Tjoa, A. M. (n.d.). The Security Issue of Federal Data Warehouse in the Area of Evidence Based Medicine. Retrieved from Wit: http://www.wit.at/research/publications/documents/paper-Stolba-Banek-Tjoa.pdf