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After reading statement below, give a conclusion of what you thought

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After reading statement below, give a conclusion of what you thought. 

 

Healthcare Operations Management

             Recently, there have been allegations of fraud regarding HCA Healthcare billing practices to the Centers for Medicare and Medicaid (CMS). According to Victoria Bailey from RevCycleIntelligence, "The alleged Medicare fraud scheme consisted of HCA Healthcare emergency rooms admitting patients for inpatient stays regardless of medical necessity and over charging Medicare by $1.8 billion. (Bailey. 2022)" 

Revenue Cycle

Let's begin with HCA Healthcare's' revenue cycle department. It is the duty of the revenue cycle personnel to ensure that all billing for CMS and payers' guidelines are being met when sending out claims for reimbursement. The first step that should be taken is to implement the DMAIC method. The DMAIC method will allow the revenue cycle department to determine: 1. Why ED patients are being admitted without proper medical necessity being present? 2. Determine what the current process is for admitting patients to an inpatient status? 3. Analyze why the current process is in place? 4. Improve the current process by reviewing current CMS inpatient admitting guidelines and update current facility guidelines accordingly, retrain all staff related to the current process on the new process, and creating a timeframe to conduct inpatient admittance audits frequently. 5. Compare past and present data to determine if the newly implemented process has had a positive effect on the proper admission of those patients requiring an inpatient stay? The next step that I recommend would be for the revenue cycle department to begin collaborating with the Clinical Documentation Improvement (CDI) department. CDI and inpatient charging go hand in hand because "Clinical documentation is at the core of every patient encounter. In order to be meaningful, the documentation must be clear, consistent, complete, precise, reliable, timely, and legible to accurately reflect the patient's disease burden and scope of services provided. (AHIMA. 2022)"

Coding

            The inpatient coding department at HCA Healthcare has been a key player in the accused fraudulent activities by Upcoding. Upcoding is the process of adding additional or designating more severe diagnosis codes to increase revenues that are reimbursed. In the Health Information Management world, a coder (inpatient/outpatient) must never, ever, conduct upcoding. A coder is only to add a diagnosis/diagnoses or procedure codes according to what is documented by a provider. I recommend for the inpatient coding manager to review current CMS inpatient coding guidelines, begin collaborating with both the revenue cycle and CDI departments to update current coding processes, review and update current inpatient coding processes, create new performance goals, and conduct audits on inpatient accounts continuously until the new processes have been properly implemented and accepted by the inpatient coding staff. 

Emergency Department         

            Another party accused of participating in the fraud allegations are some of the physicians in the ED. Accusations are coming from a state representative, Bill Pascrell, and former employees of HCA Healthcare who have become whistleblowers. In a letter that Pascrell wrote to Health and Human Services (HHS), stated "that the complaints from HCA workers included retaliation threats if admission goals are not met. (Nurse.org. 2022)" If this is true, this explains why physicians were admitting so many patients. But the issue remains that these physicians were complicit and did not report these wrongful actions accordingly. My recommendations consist of speaking to the head of physicians and discuss current ED practices, assemble a physician staff meeting to conduct a fishbone analysis to determine why the physicians are admitting patients without medical necessity, review information gathered from the analysis, determine what changes need to made to current ED practices, explain to the physicians how unethical and dangerous it is to admit patients without medical necessity, finally, implement a new criteria for physicians to reference before admitting a patient to an inpatient status.