Problem
Part I: Critical Analysis of the Law
A. The Affordable Care Act (ACA) included an "employer mandate" for large employers to provide affordable insurance for employers or pay the penalty.
a. Evaluate one of the ACA requirements for large employers and how it would apply to a large managed care organization (MCO).
b. Why would it be important for a large employer to meet the ACA requirements? What are the consequences of non-compliance?
B. Discuss the COSO framework for internal controls and evaluate how it could be used to meet ACA employer mandate requirements. Be specific and demonstrate understanding of the risks and how the compliance tool can be used specifically to control the risks.
Part II: Strategic Compliance with the Law
You work for a small managed care organization (MCO) "Splendid Healthcare" that owns a hospital and two provider clinics in. Your MCO has 100 employees and provides health insurance through a contract with a large insurance company "Insurance Inc." Insurance Inc. follows the ACA preventive service requirements and covers influenza vaccines for your employees. Lately, these claims have been rejected by Insurance Inc. You call the Insurer and they request medical records to support the payment request for the 30 employees whose immunization claims were denied. The Insurer says you are billing the incorrect code.
A. Name and describe the law and give the code section that gives Insurance Inc. have the right to access your medical records. (Give the legal source of the right)
B. Discuss interoperability requirements. How would you honor the medical record request? What format would you use to share the medical records?
C. How would you update your EHR billing codes to ensure that future bills for the influenza vaccine are automatically billed correctly?