Imagine you were appointed the Chief Financial Officer of your hospital, and you have a new crisis to confront. Your hospital received an unannounced visit from a CMS (Centers for Medicare and Medicaid Services) surveyor following a serious patient billing complaint. Your hospital is well-known both regionally and nationally for quality and safety, but the complaint threatens the hospital’s CMS enrollment, accreditation, and reputation. The surveyor determined that violations did occur, and the hospital has 90 days to resolve the issue or lose its Medicare funding. The violations include upcoding, duplicated and phantom charges, unbundling, and incorrect quantities.
You will create a plan for dealing with this crisis. The plan should consider current business processes, strategy, and communication processes to make the plan a reality. Also, consider how the crisis affects the staff and how you can reduce the amount of stress and pressure on them. Resolving the issue is just the beginning of the process. You need to determine if there was a process or system failure and figure out the solution to that failure. You should also develop a contingency plan for the future so the hospital will be prepared in the future for similar crisis events.
You need to explain the concepts of diagnosis classification, care reimbursement, and the billing system used in the hospital and by insurance companies for reimbursement for care received. You will explain how the hospital will meet patients’ needs, priorities, and expectations in a manner that exemplifies the values of respect, compassion, justice, and community pride. You need to explain the hazards of insurance, who pays for services, and the payment methods and plans available. Lastly, include the importance of proper medical billing and coding.
Instructions
Create either an audio recording or video recording at least 5 minutes in length to explain your planned proposal to deal with the violations and return the hospital into compliance within the 60 days given by CMS.
You will need to include:
- An explanation of concepts of diagnosis classification, care reimbursement, and the billing system used in the hospital and by insurance companies for reimbursement for care received.
- An explanation of how the hospital will meet patient’ needs, priorities and expectations in a manner that exemplifies the values of respect, compassion, justice, and community pride.
- Each of the violations upcoding, duplicated charges, phantom charges, unbundling, and incorrect quantities. Then, explain what will be done so these violations will not occur again.
- A contingency plan for the future so the hospital will be better prepared for similar crisis events.
Your work will be presented in an audio or video recording, as you will be submitting your presentation to this group of hospital employees, board members, and interested citizens and groups.
Options to record include (but are not limited to) your computer (PC or Mac), Screencastify which is a free add-on to Chrome, Zoom, or using an app of your choice on a smartphone or tablet.
Submit your recording link or file to the Dropbox along with your APA formatted references you used to support your oral presentation.
Requirements
Video:
- Explains the concepts of diagnosis classification, care reimbursement, and the billing system used in the hospital and by insurance companies for reimbursement for care received.
- Explains how the hospital will meet patients’ needs, priorities, and expectations in a manner that exemplifies the values of respect, compassion, justice, and community pride.
- Addresses each of the violations upcoding, duplicated charges, phantom charges, unbundling, and incorrect quantities. Then explain what will be done so these violations will not occur again.
- Develops a contingency plan for the future so the hospital will be better prepared for similar crisis events.
- Is at least 5 minutes in length.
Expert Solution Preview
Introduction:
As the Chief Financial Officer of the hospital, I need to address the recent violations found by the CMS surveyor. The hospital has 90 days to resolve the issue or lose its Medicare funding, which can affect the hospital’s enrollment, accreditation, and reputation. In this proposal, I will detail a plan for dealing with this crisis, considering current business processes, strategy, and communication processes to make the plan a reality. Additionally, I will explain the concepts of diagnosis classification, care reimbursement, and the billing system used in the hospital and by insurance companies for reimbursement for care received, and how the hospital will meet patients’ needs while exemplifying the values of respect, compassion, justice, and community pride.
Answer:
In tackling the violations found, the hospital needs to address the concepts of diagnosis classification, care reimbursement, and the billing system used in the hospital and by insurance companies for reimbursement for care received. Proper documentation and coding assist in ensuring accurate billing and the prevention of mistakes such as upcoding, duplicated charges, phantom charges, unbundling, and incorrect quantities. As such, the hospital should bolster its documentation and coding processes, provide refresher trainings for staff, and establish an internal audit system to check for errors before billing is submitted.
To ensure patients’ needs, priorities, and expectations are met, the hospital should improve its communication among staff, patients, and families. Patient education about their treatment and any potential costs can empower them to make informed decisions and contribute to their overall satisfaction. Additionally, the hospital can focus on reducing wait times and enhancing the patient experience.
In addition to addressing the violations and meeting patient needs, the hospital should look toward the future and develop a contingency plan for similar crisis events. The plan should acknowledge any potential vulnerabilities and consider strategies for mitigating risks. Staff training on how to handle such situations should also be incorporated into the plan.
In conclusion, the violations found by the CMS surveyor need to be addressed urgently. The hospital should focus on improving documentation and coding processes, enhancing communication with patients, and developing a contingency plan for the future. By meeting patients’ needs while exemplifying the values of respect, compassion, justice, and community pride, the hospital can reclaim its reputation and ensure continued Medicare funding.
