Claims Processing Case Study Analysis
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 weeks 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, found in this weeks 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.
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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
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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.
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