Your Orthopedics Specialist’s office has NOT been getting many referrals from the largest HMO organization in your area. This has drastically affected the bottom line, as your physician’s surgical schedule has decreased. You have been tasked with finding out why.

What is the first step you would take? You hold a general round table discussion with other staff members to see if they have heard anything. During the meeting, the medical billing specialist in your office speaks up about refilling a large quantity of claims because she did not add modifiers to the procedural codes to reflect that there were other surgeons assisting during surgical procedures and had been taking calls from that particular HMO’s billing department to rectify the billing error.

1. What would your reaction be? What would be the next step to correct the issue? How would you communicate with your physician; the referring physicians; the patient? What would you recommend to implement in changes to avoid this from happing in the future? How would you rebuild the relationship with the referring HMO providers? Could this be classified as up coding? If not, compare up coding to this situation.

2.After graduating as a Medical Assistant/ Medical Administrative Assistant, you landed the perfect job at a clinic that just opened. After working there for 1 ½ years, all of the staff is called in for a meeting with the Administrator and are told that the clinic has to downsize. This means you are losing your job, as the bills are not getting paid because not enough money is coming in. But you know this to be wrong because the schedules are filled every day and insurance companies are being billed. What happened? How can this be happening? Look up the statistics on how many medical facilities open and have to close within a short time frame due to lack of money coming in.

Answer the following in your discussion. Be creative in your posting as well as in your responses to your team members.

Speculate on what you think the series of events and deficiencies may have been in this office to cause the lack of funds. Was it not filing claims timely or at all? Was it filing claims on paper and not electronically? Did this office use a Practice Management System like Medisoft? If insurance was being filed timely, was there any follow-up on those claims, i.e. calling insurance companies on their status? Were claims being filed according to the guidelines of the third-party payers? Were the physician reimbursement fee schedules high enough to pay for the services being provided to the patients and to cover overhead? Were services being pre-authorized? After entering data and completing other tasks within the Medisoft Practice Management System, do you think that if the reports were more closely monitored and shared with all office staff that the downsizing could have been prevented? What role did you play as an employee? If you were aware of the situation, how did you handle this knowledge? What would have been different if claims were filed electronically instead of paper? Do you think this could have been a problem? 3.Mary Jane Shew, a long term patient, has not been paying her medical bills to your office. Once you made contact with her, she seemed embarrassed to confide that she had recently gone through a divorce and lost her job at the same time. Money is really tight for her. Please answer the following in your discussion:

If a patient is not able to pay due to financial challenges, what can you do to work with this patient in order to eventually obtain payment? What are the laws governing how you can collect the debt? What information would you include in a payment agreement? What process would you take if the insurance company is not paying timely and each time you call to check on claims-you are told that the claim is not on file? What would you do? How would you effectively communicate with the patient in a sensitive manner that there is a problem and you need their help?


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