EVALUATE AT LEAST THREE (3) TYPES OF ABUSE OR FRAUD THAT MAY OCCUR DURING THE COURSE OF MEDICAL CODING AND BILLING ACTIVITIES.

EVALUATE AT LEAST THREE (3) TYPES OF ABUSE OR FRAUD THAT MAY OCCUR DURING THE COURSE OF MEDICAL CODING AND BILLING ACTIVITIES.

You are a healthcare executive of a large hospital, serving as director of health information. You have been advised that there are serious concerns regarding the competence of the facility’s billing and coding staff. To address these concerns, you will develop an action plan. Please complete your action plan as indicated below in Parts 13.

Part 1

Competency Assessed

Determine policies and procedures to monitor abuse or fraudulent trends

Instructions

Evaluate at least three (3) types of abuse or fraud that may occur during the course of medical coding and billing activities. Determine at least three (3) organizational policies and procedures that monitor such activities and critique the effectiveness of each policy/procedure.

Part 2

Competency Assessed Create and implement staff orientation and training programs

Instructions

Based upon the trends of abuse or fraud that you identified in Part 1, develop both a new employee orientation program and an ongoing training program for medical billing and coding employees. Design outlines of each training program and construct the learning activities involved. You should also indicate a leadership approach that you would use in the implementation of the programs.

Part 3

Competency Assessed

Evaluate initial and ongoing training programs

Instructions

Develop a plan to evaluate the training programs at “time of launch” and again at periodic times over the next two (2) years. Describe the methods used to evaluate the effectiveness of each training program.

Part 4

Competency Assessed

Facilitate the use of enterprise-wide information assets to support organizational

strategies and objectives

Background

An information asset is a body of information that is defined and managed as a standalone, single unit that can be shared and exploited to the organization’s benefit. It is referred to as an asset because it has financial value to the organization. Enterprisewide information assets that are common to large health care organizations include billing systems, EHR/EMR, master patient index, clinical automation systems, patient portals, personal health records, telemedicine, health information exchange (HIE), clinical applications (lab, pharmacy), etc.

The enterprise data warehouse (EDW) is a repository of high value data from different information assets and corporate systems/applications. The data contained in an EDW can be integrated for many strategic uses across the enterprise. Strategic objectives might include activities and initiatives designed to improve quality, safety, cost, productivity, etc.

To complete Part 4, conduct research into the topic of data warehousing in health care organizations and then answer the following:

1. List the benefits of an EDW to a health care organization. 2. Prepare a strategic objective and explain how it could be facilitated through use of a data warehouse. 3. Select two (2) information assets from the list above. Through a data warehouse, analyze and demonstrate how data from those two assets could be used to accomplish the identified strategic objective.

Explanation & Answer

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