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Healthcare Compliance and Coding Management Effectiveness

Task: Use the scenario below to complete the following assignment:

A. Discuss how you would systematically proceed with the challenges presented in the scenario below.

1. Analyze the various job functions of the current staff.

2. Analyze the various concepts and processes behind each of the following:

a. Code look-up software

b. Encoder software

c. Charge description master table

3. Explain how you would determine job functions needed at both the hospital and the new clinic.

4. Discuss how you would structure a plan for recruiting, hiring, and retaining staff in both departments.

a. Identify others in the organization who may be helpful to your planning.

b. Describe how challenges you may encounter during this planning process could be addressed.

B. Discuss concerns related to productivity and quality standards as presented in the scenario.

1. Explain how you would identify these concerns.

2. Explain how you would address the concerns you identified.

C. 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. 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.

Healthcare Compliance and Coding Management Effectiveness Scenario

You have recently taken a position as supervisor for a health information management (HIM) department at a rural hospital. Your staff consists of three coders who all perform inpatient coding services. One of these coders also performs coding services for a physician who treats patients in a small outpatient center attached to the hospital.

You also manage a front office employee whose job duties are answering phones, assisting walk-ins with release of information and other requests, filing, and retrieving health records from hospital departments. The hospital implemented an electronic health record about six months ago, but there are still many providers using paper documentation during this transition period.

The chief financial officer (CFO) informed you yesterday that the hospital is purchasing an existing outpatient clinic located in a small town about 50 miles from the hospital. Currently, this clinic has one provider who sees 2030 patients daily. There is a local lumberyard and small farm equipment manufacturing plant in town, both of which contract with the clinic for medical services for injured workers.

The CFO anticipates the clinic may be more convenient for some patients, and there may be a decrease in patients seen at the hospitals outpatient center. The CFOs preliminary projections for patient numbers indicate that you will need to eliminate one of your coding positions within the next six months. The CFO informed you that the clinic has several long-term employees comprised of nursing staff and a front office staff member who performs coding and billing functions while also attending a local community college to become a registered health information technician (RHIT).

Today when you came into work, you overheard your staff expressing concern to each other about the rumor they heard about one of them being fired. They quickly quieted when you arrived and went to their own desks to begin working. Later, one of them came to you as spokesperson for the group and explained their concerns, asking you for the truth. You explained that you needed to gather more information from your superiors and promised a staff meeting before the end of the week to discuss the issue. The spokesperson left your office looking stressed.

You worked most of the morning on several rejected Medicare claims left from the previous HIM director. You had hoped to begin reviewing the policy manual to determine HIM department quality standards and department processes because the nature of some of these claims troubled you. When you asked about some of these long-standing claims, the CFO just shrugged and told you to handle it.

Your thoughts were interrupted by a phone call from the hospital charge master coordinator who was calling for information about the position at the clinic. The coordinator lives about 10 minutes from the clinic and would enjoy eliminating the long drive to the hospital each day. As a 15-year employee with the hospital, the coordinator feels the job offer would be well deserved. You politely express thanks for the call and explain that any interest should be directed to the human resource office. After the call, you sit at your desk wondering why you did not just keep your position as coding coordinator back in your hometown. Maybe this cross-country move was not such a good idea after all.

Healthcare Compliance and Coding Management Effectiveness

Proceeding with the challenges systematically

            The case scenario under analysis presents several challenges. The first challenge is that regardless of the fact that the rural hospital has an electronic health record (EHR) system; there are some providers who still use paper documentation during the transition period. To ensure that all the providers embrace and use EHR, the transition will be managed on both complex and different levels including institutional, technological, cultural, financial, and administrative. There will also be refresher courses to ensure that the providers are able to use the different software applications including the electronic document management system, integration with cardiology, radiology, and laboratory systems, and computerized physician order entry (Stevenson et al., 2008). A number of change- management dynamics will be tried out with an intention of challenging those involved in the transition and promoting the use of EHR by all providers. A feedback mechanism is also important so that the providers will be able to report the challenges they are experiencing with the use of EHR, and in turn, they will be advised on how to overcome them.

            The rural hospital failed since the intention to eliminate one of the coders was not kept confidential. This information leaked out and made the staff worried. Instead of attending to their duties, they are more focused on discussing the rumor. A spokesman is sent to confirm the rumor and is promised that more information will be gathered from the superiors and a staff meeting held. The atmosphere at the hospital is evident that the staffs are unsettled and have no morale for work since they are not sure who will be eliminated. In the light of this discussion, honesty and communication are very key in handling this situation (Westra, Solomon & Ashley, 2009).  The termination is to take place in six months time but the management at the hospital should engage in a fair, consistent, methodical, and written layoff process. There should be a written justification of the desire to terminate, a written procedure through which the coders will be selected, and a termination policy. In addition, there is need for a release and severance agreement, Human Resource’s role, management’s role, and selection criteria (Stevenson et al., 2008).  After the candidate to be terminated is identified using the also criteria such as education level, level of experience, age, and performance, an advance notice should be issued to the person. The hospital’s attorney should be involved in the entire process and confidentiality should be maintained (Wu et al., 2006). It is important for the hospital management to consider options such as telecommuting, workweek schedule, wage reduction, or transferring the coder to the outpatient clinic since the provider there is overburdened by attending to many patients every day.

            Another challenge is that there are several troubling rejected Medicare claims from the past HIM director. The CFO (Chief financial officer) also seems unconcerned about the long-standing claims and tells the HIM supervisor to handle them (Stevenson et al., 2008). The HIM supervisor should first go through the policy manual so as to familiarize himself with the HIM department’s processes and quality standards. After this, he will be able to validate the soundness of the rejected Medicare claims and follow the necessary procedures in settling them (Brown, 1998). The CFO should have first ensured that all things were settled and there were no pending claims before the previous HIM director left. If there are claims that are incomprehensible, the previous HIM director can be called over to settle issues to avoid any legal proceedings.

            The hospital charge master coordinator seems less concerned about his work. The hospital charge master coordinator has a crucial role in the hospital and the fact that he lives 10 minutes away from the hospital is sufficient evidence that he is lazy and cares less about the running of the hospital. The HIM supervisor should liaise with the relevant management officials to ensure that the hospital charge master coordinator adheres to his job description guidelines and is present to attend to his roles (Wu et al., 2006). Truly, the hospital charge master coordinator should direct his job offer concerns to the human resource office. Additionally, he should make an application for the same and he should also be subjected to the selection criteria. His selection should not be based on his long service at the hospital but his performance and dedication.

            It is inappropriate for the clinic to have one provider since seeing many patients in a day means the provider will be overwhelmed and may diagnose wrongly or give wrong medications. In a nutshell, all health care needs of the patients are not met sufficiently and, therefore, there is a need to employ more providers. The front office staff and nursing staff should not perform billing and coding functions but should stick to their roles. This will prevent errors in coding. To solve this, there should be no coder sent home but the coders should be distributed well to ensure efficient accomplishment of their roles.

The current staff’s job functions

HIM (Health Information Management) department’s supervisor

            The HIM supervisor is accountable for coordinating, planning, and performing all maintenance aspects of high standard medical records and appropriate information management systems. He also sets the policies for disclosure and use of confidential patient information and responds to information requests. He should also ensure that the staffs are familiar with the established policies as far as patient confidentiality is concerned (Westra, Solomon & Ashley, 2009).  


            The medical coder helps the doctor in understanding the treatments that are likely to work best for particular patients based on prior therapies and prognosis (Brown, 1998). They also make sure that providers adhere to the laws related to medical records. Another task is giving doctors and hospitals the data that can be tracked for the most effective therapies. The coder should sort through patient charts so as to assign codes and ensure that providers are appropriately reimburses for the services offered. He should go through nurses’ and doctors’ notes to determine the exact services received by patients. He should make easier the process of insurance companies reviewing and processing the received claims.

Front office employee

            This employee is involved in mainly administrative roles. She should welcome the patients, check them in for emergency services or appointments, update their information, and obtain insurance information. She also maintains keeps and maintains medical records. Other roles include scheduling appointments, processing insurance forms, updating insurance information, filing patient records, submitting insurance claims, and verifying insurance coverage. The front office staff should ensure patient details are in order and ensure the system has correct patient information.

Chief financial officer (CFO)

            The CFO has three key roles. The first is controllership and it involves reporting and presenting timely and accurate historical financial information since the timeliness and accuracy of this information is relied on by many people (Westra, Solomon & Ashley, 2009).  The second is treasury role where the CFO is held accountable of the hospital’s current financial condition. Therefore, he should decide how the hospital’s money will be invested and keenly consider liquidity and risks. He is also in charge of the capital structure and identifies the best mix of internal financing, equity, and debt. The final job function is forecasting and economic strategy in that he identifies and reports the most efficient areas and how the hospital can capitalize.

Clinic provider

            The provider evaluates injuries and disease. In addition he identifies the cause of conditions and delivers the necessary treatments via different venues including counseling and rehabilitation. The provider also provides long- and short-term care to patients and plays the role of educators for preventive services. He should also play administrative roles by following guidelines and laws, ensure insurance policies are utilized appropriately, keep medical records, and guard patient privacy (Stevenson et al., 2008).

Nursing staff

            The nursing staff should carry out the nursing care of the assigned patients. Her job functions include discharging and admitting patients, instructing and assisting patients and their families, bathing, removing and giving urine pots, bed pans, and hot water bottle, making beds, feeding, distributing milk and diets, and preparing special meals Wu et al., 2006). In addition, she should attend meetings, evaluate and review patient progress, and administer medications. She is responsible for assessing patient conditions and reporting back to the doctors for more assessment. They should also implement patient care programmes, clean cuts and wounds, coordinate community outreach programmes, and review the patient’s progress constantly.

Hospital charge master coordinator

            Basically, his role involves generating management reports that are related to resource utilization, optimizing revenue generation, and maintaining compliance with requirements from 3rd parties. Other related roles include cost reporting, cost accounting, cost management, and ensuring decision supports are carried out as assigned (Stevenson et al., 2008). He should coordinate and recommend the need for consultants in specialized areas. He is supposed to coordinate closely with other employees including the upper management, information system personnel, and coding personnel. He is in charge of the Charge Master Review Team and should resolve reimbursement problems.

Human resource administrator

            The job functions of the human resource administrator is in areas such as staffing and recruiting, planning performance and improvement systems, organization development, employee on-boarding, training, and assessment, employee relations, charitable giving, employee counseling and services, benefits and compensation administration, and employee health and wellness, welfare, and safety. In the presented case scenario, the human resource should assess the need to retain the present employees or employ others. In doing this, the heads of various departments should present their views regarding these needs.

Concepts and processes

Code look-up software

This software saves time greatly. The software includes a CPT code database that allows simple and fast access to the codes from the medical billing system that were updated lastly. As a result, there is generation of error-free and accurate claims, which guarantees a ninety five percent clean claim rate (Berg, 2003).
Encoder software

The coding and reimbursements’ productivity can be increased greatly if the DRG optimizer and encoder is integrated in the hospital information system. Coders can simply hit the hotkey from the clinical abstracting screen and enter the encoder. Following this, the clinical abstracting screen provides all the relevant information to the encoder, which includes Medicaid and Medicare information. The encoding software offers the CPT-4 and ICD-9 codes and helps the coder to achieve optimal DRG. After this process is complete, the coder can hit another hotkey and the procedures and diagnosis will be transferred automatically to clinical abstracting screen. encoderPro searches HCPCS, CPT, and ICD-9-CM level II medical codes. This increases accuracy and ensures auditing ease for compliance.
Charge description master table

This is a file with the principal elements for pricing, coding, and identifying all the items that are given to a patient including supplies, services, and procedures. The charge description master (CDM) handles the charging of the items for a bill (Brown, 1998). CPT/ HCPCS, revenue codes, coverage issues, and billing guidelines can be found in HIM 10 for the Medicare patients. The CDM shows the department number, service item number, service item description, general ledger number, UB92 revenue code, CPT/HCPCS code, and price. The CDM table is associated with numerous financial benefits. The process of monitoring, maintaining, and developing the chargemaster as well as its pricing scheme require multiple hospital employees who are supervised by the chargemaster coordinator. Some of its data elements include pricing, billing codes, and charge descriptions. It also communicates with other software systems to support standard billing requirements.

Determining job functions at the new clinic and hospital

            So as to determine the appropriate job functions at the new clinic and hospital, it is important to assess if there are some departments with more employees than the workload and if there are other departments where employees are overworked. After this, it will be easier to determine the need to recruit and hire more employees or lay off others. The provider at the clinic is overworked since he sees 20- 30 patients every day. The need for more employees should be assessed at the clinic. In my opinion, the coder who is to laid off can be sent to work at the new clinic if it requires a coder. Another job function that should be assessed keenly is the hospital charge master coordinator. His worth in the hospital in the hospital should be determined and if need be, another one may be hired (Brown, 1998). The performance of the current employees should be a key concern in determining job functions. Considering that the hospital is planning to expand through the new clinic, there might be a need for new employees.

            Departmental heads and patients should also be assessed to determine if more employees are required. Departmental heads should determine if their employees under them are overworked, underworked, and if they perform as required. In addition, patients who have ever been attended in the hospital can be interviewed to determine if they waited for too long before being attended and if they were satisfied with the quality of service they received.

A plan for recruiting, hiring, and retaining staff

            The hospital will use a well-structure selection and recruiting program that will comprise of the following steps;

  1. Develop an accurate job description for every position, which reflects the roles, skill sets, personality attributes, and relevant experience (Stevenson et al., 2008).  
  2. Compile a ‘success profile’ of ideal employees for principal positions. This will help in identifying the attributes and skills required in the various positions.
  3. Draft the advertisement that describes the position and key qualifications.
  4. Post the advertisement in a medium where it will reach the potential candidates.
  5. Come up with phone-screening questions that will help in identifying qualified candidates and eliminating everyone else.
  6. Review the resumes to identify the best candidates (Berg, 2003).
  7. Screen the selected candidates by phone.
  8. Select the successful candidates for interviews from the phone interview’s responses.
  9. Assess the potential candidates for their attributes and skills using proven assessment tools such as a good test.
  10. Schedule and conduct interviews.
  11. Select the candidates for various positions.
  12. Conduct a background check on the candidate to uncover potent problems not identified from previous interviews and testing.
  13. Present the offer to the candidate.
  14. Have the candidate sign the agreement contract and discuss training needs and compensation levels.

Employees at the hospital can be retained though being offered competitive packages, incentives, promotions, fostering employee development, engaging in open communication, financial rewards, and making them know what is expected from them.

People who are helpful during the planning

            During the planning process, it will be important to involve the human resource department, heads from various departments so that they can identify the need to hire or terminate, the head of the new clinic, other heads who have worked in the hospital for a long period, and the hospital’s shareholders (Westra, Solomon & Ashley, 2009).  

Addressing the challenges encountered during the planning process

            The challenges that are likely to be experienced during the planning process will be addressed through sound communication and reasoning. It is important for the hospital management to consent regarding how all employees, new and existing, will be treated. The challenges that arise during planning should be discussed and addressed openly. The vote of the majority can be a better option for solving the issues. However, it is also important to consider the views of every participant. All people present during planning should be given an opportunity to present their views so that there are no complains in future. The hospital’s protocol in regard to recruiting, hiring, and recruiting will be adhered to strictly. This avoids bias and favoritism of some of the planners. The hospital can also seek advice from other experienced institutions to determine how they react to and respond to similar issues.

Quality standards and productivity concerns

            In the presented case scenario, the quality standards revolve around rejected Medicare claims while productivity is related to the hospital charge master coordinator, coders, and CFO (Westra, Solomon & Ashley, 2009). There is also a concern for the provider who attends 20-30 patients since he might be too overworked to ensure quality care. The hospital charge master appears unconcerned about his role at the hospital and, therefore, this productivity should be evaluated. The productivity of the coders needs to be assessed so as to determine if they are all required. The CFO is unproductive in that he is less concerned about the unsettled claims and does not care how they are handled.

Identifying the concerns

            The previous HIM director left a number of rejected Medicare claims. The long-standing claims are an indication that quality lacks in regard to the claims. The appropriate procedures or conditions for reimbursement may have been disobeyed a long time ago, thereby resulting to the long-standing claims. The nature of some of the claims was troubling (Wu et al., 2006).

            The roles of the hospital charge master coordinator, coders, and CFO should be assessed keenly and matched to their productivity. The CFO seems less concerned about the issue of the claims regardless of the fact that this is one of the areas he is accountable to. Is the hospital’s productivity and growth being affected by his ignorance? The hospital charge master coordinator fails to go to the hospital to assess the running of the hospital and prefers to make phone calls. He should be assessed on his contribution to growth and productivity (Berg, 2003). Finally, there are three coders in the hospital. It should be determined if they are doing their roles or if this area has more employees than is necessary. The productivity of each coder should be evaluated.

Addressing the concerns

            Resolving the long-standing claims will involve the HIM supervisor reviewing the policy guidelines to determine the quality standards at the HIM department as well as their processes. This will help the HIM supervisor to ascertain the validity of the claims and then take the necessary measures including reimbursing the affected. The concerns on hospital charge master coordinator, coders, and CFO can be addressed through reminding each of his job function and ensuring that they are carrying out their roles to the letter. Moreover, there is a need to determine if the CFO and hospital charge master coordinator are still interested in their jobs so as to maintain the integrity and productivity of the hospital.

References Berg, M. (2003). Health information management: integrating information and communication technology in health care work. New York: Routledge.

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