Carlos Albizu University Healthcare Regulatory Compliance and Accreditation Essay

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Healthcare Regulatory Compliance and Accreditation APA Style Reply

External Audit Scenario Reply to each Peer about their post.

External Audit Scenario Reply to Rylee:

Hello Class and Professor Hughes,

For our week seven discussion we were asked to explain how we would identify and implement corrective methodologies to improve processes after an audit reveals deficiencies. Moseley (2015) explains that auditing is a rigorous, focused, and structured process designed to evaluate the operational health of distinct parts of an organization, identify problem areas, and provide the basis for corrective steps. Most organizations employ an accounting firm to conduct an annual audit of their financial statements. A compliance audit serves a similar purpose in examining an organization’s legal health.

If the audit revels a deficiency that warrants a corrective action plan to improve the processes. If the report were to show that there were deficiencies for claims that were deemed not medically necessary, then I would need to investigate into why the claim was found to be not “medically necessary” and work with the specific coding and billing department to ensure there were no discrepancies that were overlooked. The investigation would also be used as a learning experience for the department and I would have managers and employees involved in the evaluation of whether the claims are not have met the statutes for a medical necessity. It would also be important to ensure that the correct ABNs are being used, if not, then claims and compliance processes would need to be reevaluated, constructed, taught.

Reference:

Moseley, G. B. (2015). Managing legal compliance in the health care industry. Burlington, MA: Jones & Bartlett Learning.

External Audit Scenario Reply to Priscilla:

Compliance auditing is extremely important for an organization. According to Moseley (2015), “Auditing is a rigorous, focused, and structured process designed to evaluate the operational health of distinct parts of an organization, identify problem areas, and provide the basis for corrective steps” (p. 255). WIth a compliance audit, it shows how well an organization can stick to laws, regulations, and standards. Also, a compliance audit can help to detect violations, minimize risks, and prevent noncompliance in order to avoid harming the reputation of the organization.

Since the audit report reveals a deficiency for a claim that was deemed not medically necessary, there are ways I could identify and implement corrective methodologies to improve processes and fix this deficiency. I would first determine the reasons as to why there was a deficiency for a claim that was considered as not medically necessary and “identify the root cause and whether the requirements for “medical necessity” are being met” (Moseley, 2015, p. 258). The next thing I would do is to educate healthcare providers again on what is considered as “medical necessity” and how to properly use the Advance Beneficiary Notice (ABN) so that no errors can be discovered during an audit again. Lastly, I would frequently review the process of verifying the claims to ensure that there is less chance for them to ever get denied or rejected. Furthermore, I believe the compliance plans will need to be updated. The reason is because the updated compliance plans can help to ensure that the auditing process runs smoothly and efficiently. The compliance plans can also help to ensure that the results that come back from an audit are free from any errors.

References

Moseley, G. B. (2015). Managing legal compliance in the health care industry. Burlington, MA: Jones & Bartlett Learning.