timer Asked: Apr 19th, 2020

Question Description

Correct claims processing is vital to the financial security of a healthcare facility. Errors in processing claims can lead to denial, underpayment, or overpayment of services rendered. All of these can have an immediate or future negative impact on healthcare providers and suppliers. We can see this happening in the example of Mosaic Internal Medicine in this week’s Introduction. There are many rules and regulations that make claims processing complex and susceptible to error.

In this Assignment, you examine a case study involving claims processing for services covered by Medicare. You will propose a plan of action that outlines how claims processing can be improved between Medicare contractors and healthcare organizations to avoid future claim errors.

To prepare for this Assignment:

  • Read the document, “Case 3: Claims Processing,” foundin this week’s Learning Resources.
  • Consider how data shown on healthcare claims are used when issuing payment for services rendered.
  • Imagine you are in the role of executive for Wisconsin Physician Service (WPS) Insurance Corporation.

The Assignment (2- to 3-page paper):

After reading the case study thoroughly from the perspective of the executive, respond to the following:

  • Propose a plan of action to the Board of Directors outlining a response to the Office of the Inspector General (OIG).
  • Recommend at least one suggestion for how the process between WPS and CMS (Centers for Medicare and Medicaid Services) could be improved.

Provide specific examples in your paper. Support your post with the Learning Resources and at least one outside scholarly source.

By Day 7

Submit your Case Study analysis.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

  • Please save your Assignment using the naming convention “WK2Assgn+last name+first initial.(extension)” as the name.
  • Click the Week 2 Assignment Rubric to review the Grading Criteria for the Assignment.
  • Click the Week 2 Assignment link. You will also be able to “View Rubric” for grading criteria from this area.
  • Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK2Assgn+last name+first initial.(extension)” and click Open.
  • If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
  • Click on the Submit button to complete your submission.

Unformatted Attachment Preview

Case 3: Claims Processing BACKGROUND The Centers for Medicare and Medicaid Services (CMS) administer the Medicare program. CMS employs Medicare contractors, including Wisconsin Physicians Service (WPS), to process and pay hospital outpatient claims using the Fiscal Intermediary Shared System (FISS). CMS implemented an outpatient prospective payment system (OPPS) for hospital outpatient services. Under the OPPS, Medicare pays for hospital outpatient services on a rate-per-service basis that varies according to the assigned ambulatory payment classification group. Under the OPPS, outlier payments are available when exceptionally costly services exceed established thresholds. Common medical devices implanted during outpatient procedures include cardiac devices, joint replacement devices, and infusion pumps. Generally, a provider implants only one cardiac device during an outpatient surgical procedure. Under the OPPS, payments to hospitals for medical devices are “packaged” into the payments for the procedures to insert devices. Hospitals are required to report accurately the number of device units and related charges on their claims. The failure to report accurately the device units and related charges could result in incorrect outlier payments. Our audit covered $32,860 in Medicare outlier payments to hospitals for 14 claims for outpatient procedures that included the insertion of more than one of the same type of medical device. The 14 claims had dates of service during calendar years (CY) 2008 and 2009. OBJECTIVE © 2018 Laureate Education, Inc. Page 1 of 2 Our objective was to determine whether Medicare paid hospitals correctly for outpatient claims processed by WPS that included procedures for the insertion of multiple units of the same type of medical device. SUMMARY OF FINDINGS Of the 14 claims that we reviewed, Medicare correctly paid eight outpatient claims processed by WPS that included procedures for the insertion of multiple units of the same type of medical device. However, for the remaining six claims, Medicare did not pay hospitals correctly. These incorrect payments were due to hospitals overstating the number of units and related charges, resulting in excessive or unwarranted outlier payments. For the six claims, WPS made overpayments to hospitals totaling $17,996. Incorrect payments occurred because hospitals had inadequate controls to ensure that they billed accurately for claims that included the insertion of medical devices. In addition, Medicare payment controls in the FISS were not always adequate to prevent or detect incorrect payments. © 2018 Laureate Education, Inc. Page 2 of 2 ...
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