Health Informatics professionals

Health Informatics professionals working closely with the revenue cycle must address quality at every level of the cycle. A thorough understanding of how the coding function impacts steps along the continuum of the cycle will help decrease the risk of errors. Awareness of the work of quality improvement organizations and attention to recovery audit initiatives helps to build a culture of compliance.

In this task, you will describe various components of the coding and billing continuum and how errors may delay reimbursement or result in concerns of fraudulent practice. You will be required to discuss how several specific government directives have impacted healthcare organizations.


A. Evaluate the importance of the following government initiatives as they pertain to the coding function:

1. Medicare and Medicaid Patient and Program Protection Act of 1987

2. Operation Restore Trust

3. Medicare Integrity Program

4. Medicare Prescription Drug Improvement and Modernization Act of 2003: Recovery Demonstration Project

B. Explain the role of a quality improvement organization contracting under the Centers for Medicare and Medicaid Services as it applies to the coding process.

C. Diagram the activities of each step of the revenue cycle in the order in which they occur.

1. Describe the work of HIM staff members during each step of the revenue cycle in which they would be involved.

D. Illustrate how you would address the following automated billing report errors:

1. The date of service on one portion of the bill for a same-day surgery was not in agreement with the date on other portions of the bill

2. The diagnosis and procedural codes were inaccurate

3. A procedure was billed to the wrong patient

E. When you use sources, include all in-text citations and references in APA format.

Note: When using sources to support ideas and elements in a paper or project, the submission MUST include APA formatted in-text citations with a corresponding reference list for any direct quotes or paraphrasing. List weblinks for all sources. It is not necessary to list sources that were consulted if they have not been quoted or paraphrased in the text of the paper or project.

Note: No more than a combined total of 30% of a submission can be directly quoted or closely paraphrased from sources, even if cited correctly.

Financial Resource Management and Healthcare Reimbursement: Course Work


Healthcare professionals are expected to offer quality evaluation and monitoring of their services. In particular, they are expected to perform documentation and coding evaluation in all their practices in the healthcare settings. These may include provision of professional services, physician practice coding, DRG assignments, in-patient coding, outpatient services that are hospital based, and provider based services. Further, professionals are expected to conduct baseline assessments, and scheduled regular reviews. This is to augment the efforts of organizational coding quality improvement initiatives. These professionals are also expected to design, and implement monitoring programs that ensure compliance with coding and billing practices in the specific organizations. The coding and billing continuum helps organizations in the complex transition process, and implementation of operation restore trust, Medicaid and Medicare Patient and Program Protection Act of 1987 and the Medicare program integrity. In addition, it will also be helpful in implementing the Medicare Prescription Drug modernization and improvement act of 2003 and recovery demonstration project (C.C, 2012).

In essence, medical coding and billing presents a peculiar set of job responsibilities. According to Center for Medicare and Medicaid Services (2010), it would be important to understand the manner in which coding, and billing works for healthcare organizations or for people who want to operate their own billing organizations. While billing can be acquired through experience in the related job, professionals have to undergo appropriate training and certification on coding. In healthcare, billing can further be broken down into various areas including hospital billing, physician billing, home billing among others. An understanding of the basics in medical coding and billing can lead to a skill set that will be significant both now and into the future.


A) Significance of the Various Government Initiatives With Regard to Coding Function

i) Medicare and Medicaid Patient and Program Protection Act of 1987

Medial coding is important because it ensures that medical diagnosis and procedures are appropriately classified. Professionals in the healthcare industry depend on medical codes to inform them on what patients are diagnosed with and the kind of treatment they obtained. The coder in this respect utilizes the transcribed notes of the physician, lab results, and patient’s records in the determination of the procedures and diagnoses to be coded (Hattan, 2008).

The Medicaid and Medicare Patient and Program Protection Act was established in 1987. The main reason why this act was initiated and passed by congress was to curb fraudulent activities and empower programs that are aimed at beneficiary protection. This act is listed on section 1921 of the social securities act. The Medicaid and Medicare Patient and Program Protection Act makes it easy for state authorities, external or internal auditors in collecting, analyzing, and retaining  information  from organizations  that are utilizing state funds  such as  the Medicaid  and Medicare  funds. This act also enables pulling information concerning state sanctions on some health care firms. Further, the act also enables the representatives of state authorities to report fraudulent activities gained from investigations to the department of health and human services. Moreover, this act requires particular organizations to gather relevant information concerning the usage of Medicaid and Medicare. The U.S department of human services and health is entitled to obtain information from health care organizations for particular reasons (Crane, 2008). Beneficiaries of the Medicaid and Medicare are expected to protect the Medicare funds at all levels of their operations.

The coding function therefore, plays a major role in ensuring that all the operations in the healthcare facility are appropriately recorded. The goal of all health providers should be to curb Medicare abuse and fraud at all levels. This points to the reason why the Medicaid and Medicare Patient and Program Protection Act stipulates stringent rules on ensuring transparency of operations/services and use of funds by the beneficiaries of Medicare and Medicaid (CMC, 2010).

Operation Restore Trust

Operation Restore Trust is a federal initiative that was established in 1995. The purpose for this initiative was to uncover abuse and fraud in the health care sector. Operation Restore Trust ensures that there are no overpayments to the selected health facilities. It also purposed to keep in check the suppliers bills in home health agencies, nursing homes and other health care facilities. Those found to engage themselves in inappropriate cases or activities are penalized through fines, civil penalties or even prosecution in a court of law. Among the functions of ORT, include regularly conducting financial audits in the particular firms by the Healthcare financing Administration (HCFA) and the OIG, criminal investigations and recovery actions. Other ORT duties include issuing administrative and civil functions, conducting inspections and surveys to long term healthcare facilities and giving recommendations on better ways of curbing Medicaid and Medicare fraud.

The operationalization of ORT mandates physicians to regularly assess re-insurance regulations to prevent themselves from incurring excessive medical liabilities and costs when undertaking contracts with health care insurers. Medical coding ensures that they are able to evaluate the most cost effective insurance policies. Physicians are expected to assess insurance policies prior to signing of the managed care contract by the insurance providers. Among the factors to be analyzed, include risks, coverage and the provision of reinsurance in the managed care. Most physicians may get bewildered concerning their expectations on managed care. However, ensuring that their offices are efficiently and well run will reduce the amount of stress they seem to undergo. Planning, monitoring and implementation of key changes are important for transparency, easy access to ORT authorities as well as checking the imbalances in financial use.

Medicare Integrity Program

The Medicaid integrity program was established in 2006 under the social securities act. This initiative was a federal strategy to curb and eliminate health provider wastes, fraud and abuse in the Medicaid and Medicare program in the yearly budget. This program is mandated to evaluate the activities of the Medicare and Medicaid providers, perform audit claims, and identify excess payments as well as educating Medicaid providers on issues related to integrity. Among the notable  regulations of  the Medicare and Medicaid  integrity  program are the services  to be  procured, procedures  for  automatic renewal, competitive  requirements  that are based on policies of federal acquisitions. It also sets out the procedure for evaluation, identification and resolving the conflict of interest. Finally, the Medicare integrity Program sets out the limitations for contractor liability.

Efforts of identifying waste areas and health care fraud do harbor a significant impact on physicians. In effectively complying with antifraud regulations and rules, physicians have to undertake internal audit and incorporate compliance programs at their facilities. Initiation of state related audit requires physicians to respond using medical documentations as per the requests. The Medicare integrity program is operated by the Centers for Medicare & Medicaid Services (CMS). Its basic role is to address inappropriate payments in Medicare fees. In this respect, this entity ensures that only the right amount is paid to specific providers. The Centers for Medicare and Medicaid Services ensures that those organizations paid this amount are legitimate, appropriately covered, rightly coded and have correctly billed services (CMS, 2013).

Medicare Prescription Drug Improvement and Modernization Act of 2003

The Medicare Prescription Drug, Modernization and Improvement Act of 2003, is an amendment of the Social Security Act in the provision of voluntary prescription drug benefit under the Medicaid and Medicare program. This act created the benefit of voluntary prescription under the Medicaid and Medicare program. This act mandates National Heath Institutions to conduct an evaluation of the current healthcare technologies as well as improving health care practice that is evidence based. In addition, the act also mandates the beneficiaries of the Medicaid and Medicare funds to conduct clinical investigations and record trends of various diseases, record and evaluate payments for regular costs. Regular and routine costs include those incurred in patient treatments, drug purchases and follow up care (OLPA, 2014).

According to section 1013 of the Medicare Prescription drug, Modernization act of 2003, healthcare professionals must involve themselves in demonstrations, research, and regular evaluations in improving the effectiveness, quality and general efficiency of the Medicare program. The act requires healthcare professionals to provide regular information pertaining to the efficiency of the medical interventions including prescribed drugs especially for the main conditions that affect the beneficiaries of the Medicaid and Medicare. The research so undertaken should emphasize on the evidence from outcomes, comparative effectiveness of the clinical practices, appropriateness and efficiency of healthcare items and services including how they are organized, managed and delivered. The result of these studies is expected to be availed to Medicaid, Medicare and SCHIP programs. Other areas where such findings may be useful are in prescribing drug plans, health plans, health care authorities and the public (DHHS, 2009).

B. The Role of Quality Improvement Organization  Contracting Under the Centers for Medicare and Medicaid Services  With Regard to the coding process

Quality Improvement Organizations (QIOs) Operate under particular contracts from the Centers for Medicare & Medicaid Services (CMS). QIOs work with physicians, consumers, hospitals, and other health care providers to refine the systems of healthcare delivery and making sure that Medicare beneficiaries receive health care that is of top quality. It should be understood that quality care can only be achieved through efficient managerial practices and incorporation of effective healthcare practices. These can be done through coding, and billing process. QIOs is committed to ensuring that disparities with regard to treatment of Medicare beneficiaries are reduced. This therefore, compels healthcare professionals to record all the patients that have received healthcare in their facilities. In essence, quality improvement organizations works closely with the Center for Medicare and Medicaid Services in ensuring that the healthcare services offered by professionals to beneficiaries of the Medicaid and Medicare are of high quality. In addition, it is also concerned on creating transparency on how the Medicare funds are utilized by the specific organizations (HFMA, 2008)

The exact role of Quality Improvement Organizations (QIOs) is to monitor the effectiveness, appropriateness and the quality of care offered to beneficiaries of the Medicaid and Medicare Fund. On this aspect, QIQ aspires to promote the adoption of Information technology and electronic health record system in physician offices with a purpose of improving access to patience information, reference data , decision data as  well as improving  communication  between the clinicians  and patients. QIOs also facilitate and coordinate the timely submission of data and information for public reporting of the performance measures with regard to quality of the particular healthcare institutions availed in the CMS website.

(C) The Revenue Cycle

The Work of HIM staff members in the Revenue Cycle

Scheduling and Preregistration

An effective revenue cycle is important in ensuring an appropriate and timely reimbursement for the provision of patient services. Such kind of efficiency will necessitate multiple systems, processes and departments to work together to enhance consistency, smooth flow of operations and reduce workload. Many healthcare facilities get to hire HIM tools, professionals, and processes to help them carry out the multiple functions making up the revenue cycle (Hattan, 2008).

In scheduling and preregistration, HIM staff members are obligated with the role of collecting information concerning demography and health insurance of the patients. They are expected to enter such information accurately in the practice management database. The HIM staffs are also expected to confirm the patient’s benefits, co-payments, and applicable deductibles through either line verification or directly calling the health insurer. In essence, the role of HIM in scheduling and preregistration procedure cannot be over-emphasized. Alongside the aforementioned roles, they as well find out the reason for the visit, collect demographic information from the patients, health insurance, and schedule appropriate appointment time for the patient and physician. The staff also verifies the health insurance coverage for the patient, preauthorization requirements as well as the information relating to the physician and then completing the particular forms.

Point of Service/Service

In the point of service, the HIM staff  are  also mandated to make copies of  patient’s  health insurance  cards in obtaining  their  health insurance  information. They enter this information in their patient’s health insurer reference log and health insurance follow up log for the purpose of future reference. They also do verify, on whether an established or returning patient has any alteration in her or his health insurance information. During check in, the HIM staff also gives the patients copies of the physician practice’s privacy and payment. This HIM staff has also to regularly do updates on the patient’s health insurance information (CMS, 2013).


The major works of HIM staff in encounter stage entails documenting the health history of the patients, diagnosis, symptoms and treatment plan offered by the physician. These also include inclusion of the ordered tests in the medical records. The documentation also involves the date, lab review, reason for the encounter, x-ray data and other ancillary services. Other documentations include the patient’s information, change in treatment, particular information for follow-ups, and the specific frequency and dosage offered.

Charge Capture and Coding

In this stage, the HIM staff assigns the appropriate clinical modification and classification of disease and CPT codes. They then document the assigned codes in the medical record and   on the physician’s super bill. The staff also reviews and verifies the codes provided by the physicians or any other health professional based on documentation in the medical record. The HIM staff contacts the health insurer for the purpose of pre-authorization, predetermination or pre-certification of the patient’s coverage of the benefit before the actual service or procedure. The health insurer’s authorization number and support documents are also documented and forwarded to other staff for billing in this stage.

Claim Submission

In the claim submission, the HIM staffs are mandated to enter ICD-9-CM fees and codes from the practice’s super bill. They may also generate a claim and mail or transmit them to the health insurer. They do this in accordance to the submission requirements, or through a clearinghouse, billing service, or application service provider. The staffs have to review all claims before they submit them in order to ensure that all the required fields in the forms are completed. Other roles of the staff in this stage include examining the number of patients that have visited the healthcare facility, payer mix for the thirty parties, and the determination of the health insurer’s claims.

Third Party Submissions

In third party submission, HIM staff members ensure that the claims submitted to health insurers are clean. Their major roles in this respect include conducting data analysis, where the trends of acceptance or denial are scrutinized in the aggregated data. They also identify any apparent discrepancy between the procedures documented and the orders supplied and the missed or misplaced charges. They as well do back end editing in processing claims as well as identifying those codes that may not effectively support the specific medical requirements. HIM staff also identifies and address discrepancies in the submission of claims to third parties. Further, they are expected to produce timely copies of patient information in support of the claims once required to do so by the insurer.

Remittance Processing and Rejections

In this section, the HIM staff do verifies the charges, which are uploaded from the billing system in the abstract system. By entering the abstract and linking it to the encoder, the charges in the encounter are uploaded to the encoder and edited using specific coding. Any medical necessity is also addressed, modified and or edited for the charge before they are transmitted. The HIM staff is also responsible for reviewing failed or rejected claims. Rejected claims are evaluated, corrected and then resubmitted for processing. HIM professionals identify consistent and recurring scenarios that make claims to be rejected. After evaluating these scenarios, they also embark on addressing the issues and rectifying the norms before resubmitting the claims. Their jobs in this respect are considered valuable since they are professionals who are well acquainted with knowledge on the revenue cycle.

Payment, Posting, Appeals and Collections

In the case when a health insurer fails to pay for claims, the HIM staff members instructs the management to appeal for the claim. Concerning posting of the payment, the HIM professionals evaluates all the claims submitted by the physician practice to the health insurer. They also ensure that Payments made to the practice physician are verified in accordance to the state’s prompt payment policy. This verification also adheres to the provision of payments stipulated in the physician’s contractual agreements with a health insurer. With regard to collections, the HIM professional implements a claims follow up procedure  as  a confirmation  that the health insurer has received the claims  and that the claims have reached them. In most cases, the health insurer or clearinghouse will do a confirmation on whether it has received the claims.

D. Addressing   Specific automated billing Errors

i) The date of service on one portion of the bill for a same-day surgery was not in agreement with the date on other portions of the bill

In this situation, I would have to  contact the responsible  authorities  in the billing  department  and  request  them to resolve  the issue  arising  from the bill conflict. I will make copies of the bill to help me illustrate the complaint to the billing office. I do believe that communication with the responsible figures will be important in clarifying this concern in the patient billing. I will also make use of the contact numbers in the bill while presenting the case. This anomaly will also be reported to the patient advocacy team in the hospital because it concerns the patient receiving quality and necessary service as required. The advocacy team will be presented with copies of the bill indicating the problem and the communication on the same problem between the billing office and me. The advocacy team will have to investigate this issue on why the date of service in one portion of the bill was aligned with the date in other portions of the bill. After evaluation of the particular issue, they will then address the issues accordingly with the particular departments. Apparently, I will also have to contact the patient’s representative in health insurance and seek their opinion on this issue. A communication with the patient’s insurance representative will help in determining the extent of the billing problem, and also ascertaining an earlier means of solving it.

ii) Inaccurate diagnosis and procedural codes

In the case when I review medical records and find that the diagnosis and procedure codes are inaccurate, I will be mandated to perform a number of procedures. First, I will have to examine this error and the type of correction it may necessitate. I do understand that in such situations, there are errors, which may be typographical and therefore, may not need correction. The other step will be to contact the payer or the physician’s office, and request for immediate amendments to the inaccuracies in the medical records. If I cannot make to meet with them physically as required, I will ask them to post, fax or email a copy of the form, which they use for making relevant amendments. I will also make copies of the record pages where there are inaccuracies. If the correction to be made is a simple one, then I will simply strike a line through the information that is incorrect and handwrite the correction. This way, the physician and or provider will locate it easily, and do easier corrections. In case there was a form to be filled, it will be stapled alongside the copy. However, for a more involving correction, a letter will be written to outline the inaccuracy and the type of correction required.

iii)  A Billing procedure made to the wrong patient

In this case, I will have to contact the hospital billing office, the physician’s office or the medical provider who might have made the mistake. I will also immediately speak to those responsible for billing and request them to make corrections and issue a new bill for the right patient.


AHIMA, (2008), Building an Enterprise Master Person Index Journal of AHIMA 75, no. 1

            56A–D. American Medical Association, (2014), Medicare and Medicaid program integrity,