Methodist hospital billing errors or Insurance claims

Methodist hospitals make errors all the time in the billing department. According to a medical-billing auditor, “more than 90 percent of bills that are reviewed are either wrong or padded beyond belief”. The Office of Compliance in the U.S. should lead in presenting accurate and complete documentation of all health services to the rendered care rather than providing guidance in billing according to Ossoff, Lampley, & Thomason. There are two kinds of codes on a medical bill, a diagnostic code and a procedural code. Any slight deviation or even simple typo could gravely impact a patient’s outcome. For example, errors can cause a higher bill or unwarranted charges or perhaps even misdiagnosis in some cases. It is estimated that as many as 80% of hospital bills have errors and that amounts to a 25% increase, on average, in how much they’re charging. Every health plan has different co-pays, deductibles, out of pocket maximums, and exclusions. With so many different plans, it’s hard to know which costs you are responsible for and which costs are covered by your plan. It is estimated that doctors in the U.S. leave approximately $125 billion on the table each year due to poor billing practices. According to healthcare and business technology, this is a stark reminder for physicians that providing optimal patient care is only one of the big factors in becoming a successful in the industry. Two of the most common factors contributing to a loss in profits:  Billing errors. It is estimated that up to 80% of medical bills contain errors. Insurance companies are very strict on correct medical billing and coding practices, and even the smallest mistake can cause an insurance company to reject a medical billing claim. This starts a long process requiring the doctor to fix the error, submit the claim a second time, and then wait (and hope) for the new claim to be accepted and processed. Medical billing errors can cause a doctor to have to wait several months or more before receiving payment for their services.  Failure to stay up-to-date on medical billing rules and regulations. These rules are constantly changing, requiring physicians and administrators to spend time and money on continuing education, software, or staff training to stay current, having a direct effect on the cash flow and profits of a practice. Secondly, medical billing is an extremely important component of the health care industry. When your doctor prescribes something, it is recorded in your medical record and you have rights to this information. Health insurance billing is complex and oftentimes confusing, and you may find yourself receiving bills for services that should have been covered by insurance or you thought were already paid for. In addition, third-party companies who take care of the Methodist’s billing are also prone to transcribing errors, as well. The greatest issue facing physicians today is not patient care; instead, many of today’s care providers are more concerned with the business side of health care, especially concerning medical billing and coding. To also add insult to injury, the economy is in such a delicate state, medical practitioner’s patients are affected as well as their own private practices. Unemployment, illegal – aliens, ACA, along with higher co-pays and deductibles, results in patients that are unable to afford medical services. In turn, practices end up losing tons of money. Thirdly, although you can’t account for everything, it is imperative that you double check your bill and if possible keep yourself a diary of the services that you have received during your hospital stay or visit. If you take into account, most if not all nurses’ work in shifts of twelve hours plus, three days straight it’s not too surprising to see key-in errors. It is also recommended that you keep a log of every test and medication you get and check it against your file, which can be ordered from the billing office. Requests fixes via certified letter and make a copy of everything. There is wealth of benefits of effective ongoing monitoring and auditing of claims processing that helps to identify mistakes prior to submission of claims, improves accuracy of medical coding and billing, and allows hospital to know their business more, according to Kusserow. As with everything else here of late, outsourcing medical billing may sound expensive upfront, according to healthcare business and technology. However, when everything is added up, it may end up being more beneficial over time. Here’s why:  Most billing services charge on a percent-basis, meaning they will only charge a percentage of the revenue they are bringing in for your company. With this in mind, they are going to be a lot more diligent about faster collections and resubmitting claims. Your current employees don’t have time to run through denied claims. A third-party professional is dedicated to this.  Employing a staff for billing purposes can get expensive. Even to hire just one new person, a practice has to think about the costs of training, the employee’s salary, benefits, and taxes, as well as compensation for turnover. Using an outside billing service eliminates the headache of training and familiarizing a staff with your billing software, procedures, coding, etc. A billing service has already trained professionals, who only make money when you do.  The amount of time doctors and nurses spend on billing and staffing concerns can be eliminated. This freed-up time can be used to care for patients – which is what you’re goal is in the first place.  Odds are, outsourced billing companies have more billing and coding expertise, and necessary resources. Even if you are still concerned with internally handling billing, an outside service can assist in providing proper software, such as EMR (Electronic Medical Records), packaged billing, and practice management. Sometimes for an added fee, there are companies that provide appointment reminders, electronic eligibility verification, patient follow-up, coding, consulting, and data reporting. For one lump sum, you can outsource services that might have been costly to handle within your practice.  Certified billing companies are compliant with the latest health care laws, like HIPAA and the Health Care Reform bill, so your staff can rest assured that the law is being followed. Many other practices with a manageable amount of patients find that handling all of the medical billing procedures in-house is more cost-effective. Here’s why:  Problems can be addressed immediately. With the billing staff only a few feet away in the same office, any problems that may arise with billing issues can be taken care of immediately and physicians will not have to wait to get a hold of a company, wait to get an investigation, or wait to get a response.  Physicians can control the productivity levels at the office. If workers are not working efficiently or productivity needs to increase, adjustments can be made accordingly since they work directly for that office. With outsourcing, the employees answer to their own company’s rules, regulations, managers, and bosses.  Billing staff has direct communication with physicians and other administrators. If there is a question about medical coding, physicians’ notes, or patient information, the billing staff can have access to the medical professionals who can best address their questions right then and there. Fourthly, whatever steps you take to resolve any billing disputes, make sure you document them in writing. Although outsourcing was once mainly used to provide such noncore services as dietary, housekeeping, and security, it has extended to top executive jobs, clinical areas, and a rising number of business functions, among them coding and billing, according to Hazelwood, Hazelwood, & Cook . Keep a record of all phone calls you made with the date and time of the call, the number you called, the people you spoke with, and what you discussed. This will be important if you ever need to follow-up on the matter in the future and will strengthen your case if you file an appeal with your insurer or the state. It is also recommended that you get request these documents as well and are as follows:  Reports by any technician handling a procedure, as well as the nurses who administer medication or shuttle you around in your paper gown  Itemized bills (request these from your doctors or hospital, possibly after your treatment visit)  Your insurance paperwork  Your own notes from each doctor visit In conclusion, there are certain types of services available to ensure the best record of care for patients and the best physician reimbursements for the services rendered. Remember when you’re done with your visit, be sure to request those medical orders from the billing office and keep them for your own record. For there have been times, when patients have received multiple claims, spanning over a short period for one single visit to the hospital. Unfortunately, this can be very frustrating to a patient and makes reconciliation impossible in some circumstances. Furthermore, patients should ask for a thorough explanation of charges from the hospital or doctor before they leave the hospital. In order to counteract these types of issues, it is recommended that you use certified mail in the event you encounter some medical billing errors. Use certified mail when requesting a corrected bill and use it to describe the problem to your insurer. Get as much documentation as possible because your claim will depend on that. It creates that paper trail that you’ll need if you so happen to find yourself in a civil court of some sort. References Hazelwood, S. E., Hazelwood, A. C., & Cook, E. D. (2005). Possibilities and Pitfalls of Outsourcing. Hfm (Healthcare Financial Management), 59(10), 44-48. KUSSEROW, R. P. (2014). Claims Processing Ongoing Monitoring and Auditing: Improves Revenue and Prevents Costly Errors. Journal Of Health Care Compliance, 16(5), 45-48. Ossoff, R. H., Lampley, S., & Thomason, C. D. (2012). Documentation: Only Required for Billing, Right?. Journal Of Health Care Compliance, 14(6), 53-61.

Analysis of how the CQI process is different from TQI.

Ante- OBAMA era and post- OBAMA era, healthcare organizations in the U.S., will continue to face some serious health care challenges. Medicare, OBAMA care, Long-term care (LTC) and Insurance are some of the issues that are currently on the brinks of change. However, despite all the down play and rhetoric, OBAMA care, has offered relief to countless individuals and families. The U.S. health care industry, has continually improved their services to provide the highest quality at the best cost over the past few years. Continuous Quality Improvements (CQI) is an approach to quality management that builds upon traditional quality assurance methods by emphasizing the organization and systems: it focuses on "process" rather than the individual; it recognizes both internal and external "customers"; it promotes the need for objective data to analyze and improve processes. CQI has been used more in the manufacturing world as compared to the healthcare industry. In addition, CQI is an analytical decision making tool which allows you to see when a process is working predictably and when it is not. The core concepts of the CQI are as follows: Core Concepts of CQI Quality is defined as meeting and/or exceeding the expectations of our customers. Success is achieved through meeting the needs of those we serve. Most problems are found in processes, not in people. CQI does not seek to blame, but rather to improve processes. Unintended variation in processes can lead to unwanted variation in outcomes, and therefore we seek to reduce or eliminate unwanted variation. It is possible to achieve continual improvement through small, incremental changes using the scientific method. Continuous improvement is most effective when it becomes a natural part of the way everyday work is done. The CQI is managed and led by the individuals or members who are able to analyze and interpret the data and then translate those interpretations into action. The traditional approach to strategic planning processes starts with an analysis based on SWOT (strengths, weaknesses, opportunities, threats) or its reframed counterpart TOWS (threats, opportunities, weaknesses, strengths). Secondly, in 1987, the Joint Commission for Accreditation of Health care Organization (JCAHO) , launched the “agenda for change” , which were initiatives that were designed to base accreditation of health care organizations such as hospitals , clinics, and long-term health care facilities on implementation of a quality improvement model of management . Just here of late, quality health care is well sought after. Consequently, leaders in every field especially the health care industry are constantly striving for quantifiable evidence , evidence that validates the data that substantiates improvements initiatives or strategic methods of improvements in production of services and delivery. Hospital leaders are responsible for indoctrinating healthcare workers a strong quality driven work environment. Every professional should continue to strive to provide the best affordable quality service or health care with zero defects. For example, this Pareto chart reflects trending patterns cited during production processes. This Pareto chart tool, lean or other six sigma methodologies can be used to engage the medical providers, by providing illustrations of data that is representative of some of the varied defects, which occurred or were cited during quality inspections of production of services. The CQI system was all part of the bigger vision which is the total quality of management (TQM) system or Quality Management System (QMS). “Increased emphasis is being placed on the continuous quality improvement (CQI) education of residents of all specialties.” (Jones, K. B., Gren, L. H., & Backman, R. (2014)) Total Quality Management (TQM) is a comprehensive and structured approach to organizational management that seeks to improve the quality of products and services through ongoing refinements in response to continuous feedback. Fourthly, leaders are able to use these important pieces of information, when urgent business decision making is necessary and gage the resources needed to perform general job duties. This advantage gives the managers insight of what areas have higher risk probability, and how to address and more important create a contingency plan, in any event. Taking precautions on the front end, and addressing the issues before they happen is always good sound management. Return on Investment (ROI) provides a figure for the ratio of savings to the cost of the investment. Businesses benefit from implementing strategic goals that aim total Quality Improvements (TQI). TQI address the upstream or preventive management. The results of a TQI are most beneficial when planning for long-term business goals and quality and applicable when making assessments and gauging. It is imperative; we properly take into account the information that is possible in these reports. According to Farruggia, to accomplish the necessary transformation in TQI , the infrastructure of the organization must change. In conclusion, “in the current market economy, companies are constantly struggling to achieve a sustained competitive advantage that will enable them to improve performance, which results in increased competitiveness, and of course, profit.” (Cătălin, S. H., Bogdan, B., & Dimitrie, G. R. (2014)). Improved quality inherently lowers costs as it provides better service. The benefits of using a CQI include higher quality of service delivered, happier patients and customers, and lower costs. According to , Mayer, Jones, Dowling-Lacey, Nehchiri, Muasher, Gibbons, & Oehninger TQI is sometimes confused with quality control (QC) and quality assurance (QA), there are major differences between the three quality plans: (i) QC is an activity designed to ensure that a specific element within the laboratory is functioning correctly; (ii) QA is a comprehensive program designed to look at a laboratory as a whole and to identify problems or errors that exist in an attempt to improve the entire process; (iii) TQI is also a comprehensive monitoring process designed not only to detect and eliminate problems, but also to enhance a laboratory's performance by exploring innovation and developing flexibility and effectiveness in all processes. Quality improvement requires five essential elements for success: fostering and sustaining a culture of change and safety, developing and clarifying an understanding of the problem, involving key stakeholders, testing change strategies, and continuous monitoring of performance and reporting of findings to sustain the change. References 1. Cătălin, S. H., Bogdan, B., & Dimitrie, G. R. (2014). THE EXISTING BARRIERS IN IMPLEMENTING TOTAL QUALITY MANAGEMENT. Annals Of The University Of Oradea, Economic Science Series, 23(1), 1234-1240. 2. Jones, K. B., Gren, L. H., & Backman, R. (2014). Improving Pediatric Immunization Rates: Description of a Resident-Led Clinical Continuous Quality Improvement Project. Family Medicine, 46(8), 631. 3. Farruggia, M. J., & Farruggia, M. H. (1995). TQI: BLENDING THE OLD WITH THE NEW. Nursing Management, 26(4), 67-68. 4. Mayer, J. F., Jones, E. L., Dowling-Lacey, D., Nehchiri, F., Muasher, S. J., Gibbons, W. E., & Oehninger, S. C. (2003). Total quality improvement in the IVF laboratory: choosing indicators of quality. Reproductive Biomedicine Online (Reproductive Healthcare Limited), 7(6), 695-699.