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Compliance Strategies Assignment -

Purpose - Compliance Strategies Assignment Description - You have just been hired as the Chief Compliance Officer for Herzing Healthcare. This is a newly created position, and you are the first position to hold this position. One of the first things on your "to-do" list is to identify indicators to monitor compliance. Using information from the OIG and RAC, determine 10 compliance indicators. Create a policy/procedure which outlines the chosen compliance indicators, the compliance threshold, and justification for the recommendations.

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Answer - OIG & RAC

OIG

OIG helps healthcare providers and care givers fulfil relevant federal healthcare rules and regulations. The OIG provides compliance program for protecting from inaccurate claims. It is the responsibility for the physician to verify whether the submitted claim to government health care program is true or not (OIG 2000). The small group or physicians should follow the program to implement the OIG compliance program. The following are the steps for building the compliance program such as

Developing standards for conduct

For developing standards the following risks are identified such as

  • Billing and coding
  • Necessary and reasonable services
  • Documentation
  • Improper kickbacks, inducements as well as self-referrals
  • Illegal use of the symbol of Medicare in advertising
  • Third party billing of physician
  • Teaching physician billing
  • Arrangements for gain sharing
  • Limitations in billing for the non-participate physician
  • Certification for home care services as well as supplying of medical equipment
  • Billing for professional courtesies
  • Rental for office space of physician for suppliers

Establishing method for oversight

Staff training

Communication

Performing monitoring and auditing function

Enforcing standards

Responding for detected offenses

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RAC

The indicators for the compliance are as follows (RAC 2019):

Financial

Dashboard

Revenue cycle

The following data are included for RAC such as

  • Claims of the inpatient
  • Claims of physician
  • Claims of medical equipment those are durable
  • Claims of outpatient
  • Claims of skilled nursing
  • Data of enrolment

The risks of the compliance are assessed using the fraud triangle. It has 3 components such as

  • Pressure
  • Rationalization
  • Opportunity

The dashboard has the following details

Frequency of billed claims

  • Code of diagnosis
  • Code of procedure
  • Stay length

Payments & denials

  • Class of financial
  • Type
  • Code for revenue

The dashboard indicators help providers anticipate RAC while creating pressure for committing fraud such as

- The billed claims has suspicious trends

- Claims are targeting auditors

- Case mix of Medicare is high

The following are the revenue cycle indicators such as

- Ratio of Initial Denied claims and total of billed claims and zero payment is high

- Ratio of Initial Denied claims and total of billed claims and partial payment is high

- Denial claim and net revenue is high

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