Imagine that you are a Hospital HIM Manager. You have been asked to prepare an educational resource for some new employees at your hospital, including folks who will work in billing and coding as well as some physician practice managers. The billing manager is concerned about fraud & abuse and wants you to partner with him to develop guidelines and a training document that will be delivered live to the HIM, Billing, Finance and the Business Office employees. The billing manager is especially concerned about any fraud and abuse laws that should be followed. In relation to fraud and abuse there may be an audit process as well. The HIM department plays a vital role in the Recovery Audit Contractors (RAC) process. The HIM department must take charge of the audit process to ensure that RAC requests are received and processed on time.
Part I. Create a one page pamphlet (back and front) or booklet that can be given to current employees and included in a training handbook in the future. The pamphlet should include:
* Introduction to the topic
* An explanation of the concepts of fraud and abuse and how it relates to coding, chargemaster, claims management, and bill reconciliation processes.
* An overview of the major laws relating to fraud & abuse in healthcare, and the possible penalties for violations
* Incorporate at least two examples of enforcement actions that show serious penalties for billing fraud; you can use either this unit's Supporting Lesson Links or other examples that you find in your own research.
* Choose at least one of the "High-Risk Areas" from the OIG or RAC that you feel is relevant and propose two ways to keep your hospital from violating these laws. Be sure to relate and include in your discussion coding, chargemaster, claims management, and bill reconciliation processes.
Part II. review the table and determine the RAC for your state. Go to the RAC web address and review the procedure for requesting medical records. Using Flowchart symbols found in Microsoft Word (or any flowchart software) create a graphic that outlines the RAC medical record request process.