Professional fee billing Compliance plan

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.