Question DQ I need help please

Sep 28th, 2014
Price: $25 USD

Question description


Patient, Andrew Mahoney called the office and was very angry.  He had been in a year ago asking for an HIV testarrow-10x10.png to be performed as he believed he had been exposed.  He asked that his insurance NOT be billed and that he be paid out of pocket for the testing.  Somehow, someone filed the claim to his insurance and it went unnoticed as the charges were appliedarrow-10x10.png against his deductible. 

His angry call today was in regards to being denied life insurancearrow-10x10.png because the life insurance companyarrow-10x10.png received a health profile from his health insurance companyarrow-10x10.png which listed the diagnosis of HIV from the prior year. 

Think about how this happened. YOU are responsible for the error! This is only one of many errors you have made and now it has made a significant impact on someone else’s life.

  • How would you communicate with sincerity and extension of an apology?
  • Discuss exactly how you would repair the damage.
  • Explain what other code or codes you should have used to demonstrate exposure instead. 
  • Explain what you could do in the future to avoid doing sloppy work and making careless errors.


It is Friday September 30, 2012, and you are having lunch with a friend who works at another physician’s office.  During the course of the conversation, she asks you if your office is ready to handle the ICD-10 transition from ICD-9 Diagnostic coding.  You look at her with a blank stare and ask, “What transition?”  She explains how everything is going to change, including the format and number of digits.  You realize that since the medical billing specialistarrow-10x10.png left for maternity leave six weeks ago, that no claims have gotten billed.

  • What process will you take to get those claims filed? 
  • Is there time before Monday when the change takes effect?
  • Oh no, will it be better to electronically file the claims over the weekend in the ICD-9 format; Go thru a clearinghouse; or print everything out on paper, hoping the claims will be considered under the ICD-9 format and not under the ICD-10?
  • Explain your choice.

Your office recently decided to stock braces and crutches as you had anticipated an increase of patients coming in with sprains and fractures of body parts as summer was right around the corner and your physician wanted to service the patients better by not having the patient drive to multiple places for those Durable Medical Equipmentarrow-10x10.png (DME) items.

However, you noticed that denials are coming in from Medicarearrow-10x10.pngMedicarearrow-10x10.png Remittances are stating that they are not the payer.  However, you pull the patients cards and see Medicarearrow-10x10.png very clearly on their cards. What actions would you take to find out which payer is responsible for the Durable Medical Equipmentarrow-10x10.png (DME)?  Your physician is a Participating provider with Medicarearrow-10x10.png.  What is the problem?  Why is Medicarearrow-10x10.png not paying? 

  • Define the steps you would take to find out why Medicare is not paying and how you would solve the problem. 
  • What steps need to be taken? 
  • Who is supposed to be the payer? 
  • How do you get the claims to that payer?
  • Does any other paperwork need to be completed?  If so,what?


Your Orthopedicsarrow-10x10.png Specialist’s office has NOT been getting many referrals from the largest HMO organization in your area.  This has drastically affected the bottom line, as your physician’s surgical schedule has decreased.  You have been tasked with finding out why. 

What is the first step you would take? You hold a general round table discussion with other staff members to see if they have heard anything.  During the meeting, the medical billing specialistarrow-10x10.png in your office speaks up about refilling a large quantity of claims because she did not add modifiers to the procedural codes to reflect that there were other surgeons assisting during surgical procedures and had been taking calls from that particular HMO’s billing department to rectify the billing error. 

  • What would your reaction be?
  • What would be the next step to correct the issue?
  • How would you communicate with your physician; the referring physicians; the patient?
  • What would you recommend to implement in changes to avoid this from happing in the future?
  • How would you rebuild the relationship with the referring HMO providers?
  • Could this be classified as up coding?  If not, compare up coding to this situation.

    Refer back to the learning activity in this learning plan: 

    5..“After graduating as a Medical Assistantarrow-10x10.png/ Medical Administrative Assistant, you landed the perfect job at a clinic that just opened.  After working there for 1 ½ years, all of the staff is called in for a meeting with the Administrator and are told that the clinic has to downsize.  This means you are losing your job, as the bills are not getting paid because not enough money is coming in.  But you know this to be wrong because the schedules are filled every day and insurance companies are being billed.  What happened?  How can this be happening? Look up the statistics on how many medical facilities open and have to close within a short time frame due to lack of money coming in.”

    Answer the following in your discussion. Be creative in your posting as well as in your responses to your team members.

    • Speculate on what you think the series of events and deficiencies may have been in this office to cause the lack of funds. 
      • Was it not filing claims timely or at all?
      • Was it filing claims on paper and not electronically?
      • Did this office use a Practice Management Systemarrow-10x10.png like Medisoft?
      • If insurance was being filed timely, was there any follow-up on those claims, i.e. calling insurancearrow-10x10.png companies on their status?
      • Were claims being filed according to the guidelines of the third-party payers?
      • Were the physician reimbursement fee schedules high enough to pay for the services being provided to the patients and to cover overhead?
      • Were services being pre-authorized?
      • After entering data and completing other tasks within the Medisoft Practice Management Systemarrow-10x10.png, do you think that if the reports were more closely monitored and shared with all office staff that the downsizing could have been prevented?
      • What role did you play as an employee?  If you were aware of the situation, how did you handle this knowledge?
      • What would have been different if claims were filed electronically instead of paper?  Do you think this could have been a problem?

All these are these are DQ question so the answer dont have to be so long just want my points. Thanks

Tutor Answer

(Top Tutor) Daniel C.
School: Rice University

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Oct 5th, 2014
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