Conducting pre-billing audits can be challenging, but when done correctly, it can save organizations from spending time recoding and rebilling claims that payers deny. These audits can be conducted on the front end, in both inpatient and outpatient settings, once records have been coded.
Q: You are reviewing a computer-generated insurance claim before it is sent to the insurance carrier, and you happen to notice the patient's name on the claim?it's an old friend of yours. You quickly read the code for the diagnosis. Is this a breach of confidentiality?
Since the implementation of the Hospital Value-Based Purchasing (HVBP) Program in 2013, CMS has adjusted the MS-DRG payment for each traditional Medicare discharge. The type and amount of the adjustment, which could be a financial penalty and/or an incentive payment, is determined by the hospital's performance for defined quality measures, such as risk-adjusted mortality. Since that time, the number of pay for performance (P4P) programs and quality measures has expanded. By 2017, P4P payment adjustments will impact up to 6% of traditional Medicare revenue.
As required by The Joint Commission, a board of directors should regularly assess its performance, appropriateness of board and committee processes and charter fulfillment, adequacy of meeting structures and goals, communication with management, and other governance structures and activities. Generally, boards and their committees complete this assessment through self-surveys, internal audits, or collection of results as performed by legal services. Assessment results can lead to changes in board processes, with the goal of adapting to changing risks and environmental requirements, and improvements in governance.
