Correct claims processing is vital to the financial security of a healthcare facility. Errors in processing claims can lead to denial, underpayment, or overpayment of services rendered. All of these can have an immediate or future negative impact on healthcare providers and suppliers. We can see this happening in the example of Mosaic Internal Medicine in this week’s Introduction. There are many rules and regulations that make claims processing complex and susceptible to error.
In this Assignment, you examine a case study involving claims processing for services covered by Medicare. You will propose a plan of action that outlines how claims processing can be improved between Medicare contractors and healthcare organizations to avoid future claim errors.
To prepare for this Assignment:
- Read the document, “Case 3: Claims Processing,” found in this week’s Learning Resources.
- Consider how data shown on healthcare claims are used when issuing payment for services rendered.
- Imagine you are in the role of executive for Wisconsin Physician Service (WPS) Insurance Corporation.
The Assignment (2- to 3-page paper):
After reading the case study thoroughly from the perspective of the executive, respond to the following:
- Propose a plan of action to the Board of Directors outlining a response to the Office of the Inspector General (OIG).
- Recommend at least one suggestion for how the process between WPS and CMS (Centers for Medicare and Medicaid Services) could be improved.
Provide specific examples in your paper. Support your post with the Learning Resources and at least one outside scholarly source.
Expert Solution Preview
Introduction:
Claims processing is a critical aspect of financial management in healthcare facilities. Errors in processing claims can have adverse effects on healthcare providers and suppliers, leading to underpayment, overpayment, or denial of services rendered. This assignment involves examining a case study on Medicare claims processing and proposing a plan of action that outlines how claims processing can be improved between Medicare contractors and healthcare organizations to prevent future claim errors.
Answer:
In response to the Office of the Inspector General (OIG), the Board of Directors must implement a plan of action that demonstrates a commitment to improving the claims processing system’s accuracy and efficiency. The plan of action should include the following steps.
First, the Board of Directors must launch an investigation into the causes of the errors identified by the OIG. This investigation must be extensive and explore all possible causes, including technical issues with the claims processing software and human errors by claims processing staff.
Second, the Board of Directors must establish a training program aimed at improving the skills and knowledge of claims processing staff. Such a program should cover policy changes, compliance regulations, and best practices in claims processing.
Third, the Wisconsin Physician Service (WPS) Insurance Corporation should invest in technology-driven solutions to automate claims processing and minimize human error. Investing in technological solutions will improve efficiency and reduce the time it takes to process claims. This will provide WPS with a competitive edge in the market and improve its reputation for claims processing accuracy.
Lastly, the Board of Directors should establish a system of checks and balances that will ensure the claims processing system’s accuracy. This system of checks and balances should include an independent review of claims under dispute and clear communication channels between WPS and healthcare organizations.
Improving the claims processing system’s efficiency requires collaboration between WPS and the Center for Medicare and Medicaid Services (CMS). One suggestion for improving the process between WPS and CMS would be to explore the use of blockchain technology. Blockchain is a decentralized and secure system that allows data to be shared without intermediaries, thereby reducing costs and improving efficiency.
By leveraging blockchain technology, WPS and CMS could create a more robust, secure, and transparent claims processing system. The use of blockchain technology would enable the sharing of real-time data, minimizing errors and improving the speed of payments.
In conclusion, the Board of Directors of WPS must take decisive action to improve the accuracy and efficiency of claims processing. Through better training, investment in technology, and the use of blockchain technology, WPS can create a more robust and efficient claims processing system, with considerable benefits for healthcare providers and suppliers.
