This Is Due Sunday, November 19, By 6 PM Please Provide All

This Is Due Sunday November 19 By 6 Pm Please Provide All References

You are a healthcare executive of a large hospital, serving as director of health information. You have been advised that there are serious concerns regarding the competence of the facility’s billing and coding staff. To address these concerns, you will develop an action plan. Please complete your action plan as indicated below in Parts 1-3.

Part 1: Determine policies and procedures to monitor abuse or fraudulent trends. Evaluate at least three types of abuse or fraud that may occur during medical coding and billing activities. Identify at least three organizational policies and procedures that monitor such activities and critique the effectiveness of each policy/procedure.

Part 2: Create and implement staff orientation and training programs. Based on the trends of abuse or fraud identified in Part 1, develop a new employee orientation program and an ongoing training program for medical billing and coding employees. Design outlines of each training program and construct the learning activities involved. Indicate the leadership approach you would use in implementing the programs.

Part 3: Evaluate initial and ongoing training programs. Develop a plan to evaluate the training programs at launch and periodically over the next two years. Describe the methods used to assess their effectiveness.

Part 4: Facilitate the use of enterprise-wide information assets to support organizational strategies and objectives. Conduct research into data warehousing in healthcare organizations and answer the following:

• List the benefits of an enterprise data warehouse (EDW) to a healthcare organization.
• Prepare a strategic objective and explain how it could be facilitated through a data warehouse.
• Choose two information assets from the provided list and demonstrate how data from these assets could be used via a data warehouse to achieve the strategic objective.

Please complete all parts in a Word document of at least 1500 words, including a title page and a reference page. Use APA formatting, double-spaced, 12-point Times New Roman font. Quoting should be less than 10%, with paraphrasing used throughout. Cite at least four credible sources from the KU Library. Ensure your submission is organized, logical, and original, with proper grammar and mechanics.

Paper For Above instruction

Introduction

Effective management of billing and coding processes is crucial for healthcare organizations to ensure compliance, reduce fraud, and optimize operational efficiency. As healthcare regulations grow more complex, organizations must implement robust policies, ongoing training, and advanced data management strategies to safeguard financial integrity and improve patient care outcomes. This paper presents a comprehensive action plan addressing these areas, focusing on monitoring fraudulent activities, developing staff training programs, evaluating their effectiveness, and leveraging enterprise data assets through data warehousing to support strategic objectives.

Part 1: Policies and Procedures to Monitor Abuse or Fraud

Financial fraud and abuse in healthcare, especially within billing and coding, pose significant threats to organizational integrity and sustainability. Three common types include upcoding, unbundling, and phantom billing.

• Upcoding: This involves assigning codes that reflect higher severity or resource utilization than actual services rendered, increasing reimbursements fraudulently. Policies to monitor upcoding include rigorous audits comparing billed codes with documented procedures. These audits are effective when frequent and comprehensive but require substantial resources.
• Unbundling: Separating services that should be billed together into individual components to inflate charges. The use of automated billing systems with built-in edit checks helps detect unbundling. Its effectiveness depends on continuous updates of billing rules and manual reviews.
• Phantom Billing: Billing for services not provided. Regular reconciliation of billing records with clinical documentation and patient records helps identify such fraud. This process is effective but demands meticulous review protocols.

Organizational policies should include mandatory audits, use of advanced billing software with fraud detection algorithms, and routine compliance training. While these policies are effective, their impact relies heavily on enforcement consistency, technological investment, and staff awareness.

Part 2: Staff Orientation and Ongoing Training Program

Based upon identified fraud trends, a comprehensive training framework must be established. The orientation program will educate new hires on legal standards, organizational policies, and ethical coding practices. It will include modules on compliance, common types of billing fraud, and the importance of accurate documentation.

The ongoing training program will focus on updates to billing codes, emerging fraud schemes, and internal audit procedures. Learning activities will include case studies, role-playing scenarios, and interactive e-learning modules. Leadership will adopt a transformational approach, encouraging open communication, accountability, and continuous improvement to embed a culture of compliance.

Part 3: Evaluation of Training Programs

To assess training effectiveness, a multi-layered evaluation plan will be implemented. At launch, pre- and post-training assessments will measure knowledge gains. Follow-up evaluations will occur at six-month intervals through quizzes, audits of coding accuracy, and incident reports of fraud detection rates. Over two years, metrics such as error rates, audit findings, and staff compliance surveys will inform ongoing program improvements.

Part 4: Data Warehousing to Support Strategic Objectives

Benefits of an Enterprise Data Warehouse

An EDW facilitates integrated data analysis across multiple sources, providing real-time insights that support decision-making, improve operational efficiency, enhance patient safety, and promote compliance. It enables trend analysis, predictive modeling, and benchmarking to inform strategic initiatives.

Strategic Objective and Data Warehouse Facilitation

An example strategic objective is reducing billing errors by 15% within one year. Data warehousing can facilitate this by aggregating data across billing systems, clinical records, and audit logs to identify patterns, anomalies, and root causes of errors, enabling targeted interventions.

Using Two Information Assets

1. Billing Systems: Data from billing systems can be analyzed for coding accuracy, claim rejection rates, and patterns indicating fraudulent activity, enabling proactive correction strategies.
2. Electronic Health Records (EHR): Linking billing data with clinical documentation ensures that billed services match actual clinical notes, reducing upcoding and unbundling instances.

By integrating these assets in a data warehouse, the organization can monitor and improve billing accuracy, thus achieving the strategic goal of reducing fraud and optimizing revenue cycle management.

Conclusion

Addressing billing and coding fraud through comprehensive policies, targeted training, continuous evaluation, and strategic data management is vital for healthcare organizations. Implementing an enterprise data warehouse further enhances capabilities to identify trends, streamline operations, and support strategic goals. A proactive, integrated approach ensures compliance, mitigates fraud risks, and improves overall organizational performance.

References

• Garrido, T., & Vayá, R. (2019). Healthcare Data Analytics and Data Warehousing. International Journal of Healthcare Management, 12(3), 243-251.
• Kim, S., & Lee, J. (2020). Fraud Detection Techniques in Healthcare Billing and Coding. Journal of Healthcare Information Management, 34(2), 142-148.
• Mathews, B., & Suresh, S. (2021). Leveraging Data Warehousing for Healthcare Strategic Planning. Health Information Science and Systems, 9(1), 7.
• Roberts, T., et al. (2018). The Role of Enterprise Data Warehouses in Healthcare Quality Improvement. Journal of Medical Systems, 42(8), 136.
• Williams, P. (2018). Risks and Controls in Healthcare Billing. Healthcare Finance Review, 31(4), 88-95.