Question

The Case of the Coding Dilemma

Background: Coding is the process of assigning a billing code to a patient diagnosis. The billing code comes from a standardized code book. Each code represents a specific diagnosis and a designated amount of reimbursement by government and private insurers. Entering a higher code than is warranted will result in overpayment for the patient’s particular diagnosis. Entering a lower code than is warranted will result in underpayment for the patient’s particular diagnosis. All diagnoses are coded and billed by the assigned code regardless of how the bill will be paid.

The Situation: Joe Brown is a long-time patient of the clinic with a chronic condition. Joe recently lost his job and subsequently his health insurance. Although Joe is looking for a job, he was uninsured at the time of his most recent visit to the clinic. Joe’s visit was a follow up visit for his existing chronic condition for which he has been receiving care. At his last visit as an insured patient, the visit code entered matched directly with the diagnosis for the visit. The current uninsured visit, although for the same condition, was coded with a different code that resulted in a lower charge for the visit. This type of coding variation is a typical practice within the clinic when an uninsured patient is seen. Suzy Staff, a newly appointed member of the Corporate Compliance Committee, called the “downcoding” practice to the attention of the Corporate Compliance Committee who undertook an investigation.

Using information from this week’s required studies and at least two articles from outside healthcare research, write a 4-page case analysis to answer the following:

What are the ethical principles that relate to this case?

How does the case relate to the concept of Stewardship?

How does the case relate to the concept of Justice?

How does the case relate to the GAAP principles required by SOX of accuracy, transparency, comparability, and consistency?

What is the role of a compliance audit in this situation?

Answer 1

The essential meanings of every one of the four standards of social insurance morals are generally known and utilized frequently in the English dialect, yet they go up against uncommon significance while being used in a therapeutic setting. These standards assume a key part in guaranteeing ideal patient wellbeing and care.

- Autonomy: In prescription, self-sufficiency alludes to patient to hold control over his or her body. A social insurance expert can recommend or prompt, yet any activities that endeavor to influence or pressure the patient into settling on a decision are infringement of this rule.

- Beneficence: This rule expresses that medicinal services suppliers must do whatever they can to profit the patient in every circumstance. All methodology and medicines prescribed must be with the expectation to do the most useful for the patient. To guarantee advantage, medicinal specialists must create and keep up an abnormal state of ability and learning, ensure that they are prepared in the most present and best therapeutic practices, and should think about their patients' individual conditions; what is beneficial for one patient won't important advantage another.

- Non-Maleficence: Non-perniciousness is presumably the best known about the four standards. So, it signifies, "to do no damage." This guideline is expected to be the ultimate objective for the greater part of a specialist's choices, and implies that restorative suppliers must consider whether other individuals or society could be hurt by a choice made for the advantage of an individual patient.

- Justice: The standard of equity expresses a component of reasonableness in every single medicinal choice: decency in choices that weight and advantage, and in addition meet dispersion of rare assets and new medications, and for restorative professionals to maintain appropriate laws and enactment when settling on decisions.

Human services chairmen design, compose, and regulate the elements of the social insurance offices at which they work, and in addition alternate individuals from the staff who work there, including specialists and medical caretakers. In this manner, they assume a crucial part in guaranteeing that patients are accepting high caliber and moral treatment.

While human services executives are required to have education to enter the field, a graduate degree will help separate applicants and further progress in their profession. A Master's in Health Administration expands the information and abilities of individuals who are now working in social insurance organization or who are occupied with entering the field. Teachers from an assortment of fields under the wide umbrella of human services contribute their insight on medicinal services morals to make a training based program that will address the difficulties of the present therapeutic framework head on.

Specialists and medical caretakers straightforwardly direct every patient's wellbeing, human services heads assume an imperative part in encouraging choices about patient care, especially when the circumstance is one that may contain moral and moral issues, for example, hereditary testing preceding birth or end-of-life mind. As science and innovation additionally increment the capacities of specialists and propel the field of human services, the part of social insurance morals will change and just keep on increasing in significance. Subsequently, it is indispensable that social insurance chairmen be appropriately prepared to meet the present and future difficulties of morally helping patients get the best care.

Powerless populaces require extraordinary consideration in the plan of social insurance quality estimation systems for three particular reasons. Initial, an emphasis on the nature of care experienced by defenseless populaces could give new understanding into wellbeing framework issues or distinguishing proof of issues that generally could go undetected. Second, some helpless gatherings will probably get lost in an outright flood. Similar components that add to their defenselessness can likewise influence their capacity needs and interests enough. Third, for an assortment of specialized and different reasons, medicinal services quality issues experienced by defenseless populaces are not very much caught by estimation endeavors intended for the all inclusive community. Generally, these endeavors don't use information gathered after some time or over various diverse settings for medicinal services conveyance. At long last, since people with interminable disease and inability devour an unbalanced offer of human services assets in respect to their offer of the populace, estimating the nature of their encounters with the medicinal services framework will prompt an attention on mind-boggling expense zones.

Human services quality estimation for powerless populaces either could be embraced independently or be incorporated into general methodologies for assessing quality. The blend of general and focused on systems is destined to distinguish proficiently and viably the most elevated need quality issues for powerless populaces. Now and again, it might be more affordable to oversample one gathering in the populace to investigate whether the subgroup is encountering progressively or distinctive quality issues. In different cases, the utilization of uncommonly custom fitted measures might be more successful.

Counting powerless populaces all in all systems for quality estimation is probably going to be more manageable as time goes on and sends the critical flag that assessing quality for defenseless populaces is similarly, if not increasingly, essential. This procedure permits correlations amongst powerless and all inclusive communities when similar measures are utilized. Such methodologies might be more proficient if exceptional inspecting strategies can increase a by and large connected measure so assessing issues for powerless.

For people helpless because of monetary conditions, the way to incorporating them in checking frameworks is the accessibility of factors to distinguish such people and strategies for expediting information their examples of use into coordinated information frameworks (e.g., the encounters of uninsured people who don't document claims). For people powerless because of wellbeing status, the way to incorporation in observing is the extension of fitting criteria for assessing their care and the improvement of techniques that can bolster investigations of value issues utilizing little examples. For people who are helpless because of correspondence challenges, the way to incorporation will be the improvement of estimation devices that can be utilized with such populaces.

Wellbeing designs generally get a prepaid sum for each part to cover required administrations, however these "capitated" installments typically are not changed in accordance with mirror individuals' wellbeing and practical status. By changing installments for wellbeing status, wellbeing designs will be compensated for creating quality projects that pull in surprising expense people with unending conditions, though these motivators are inadequate with regards to while paying plans normal rates. Modifying capitated installments to better reflect wellbeing and useful status is accordingly a basic piece of endeavors to enhance the nature of care and elevate access to watch over patients helpless against insufficient care because of the nearness of interminable conditions.

Hazard modifying installments is particularly essential for Medicare, Medicaid, and different payers that have numerous recipients with critical handicap or perpetual sickness. The progressing social insurance needs that come about because of maturing, interminable sickness, and handicap highlight the significance of value and the drawback of unadjusted rates. With unadjusted normal rates, plans have a motivator to abstain from enhancing quality in ways that may pull in individuals with perpetual conditions, for example, kidney illness, loss of motion, growth, or coronary illness, who are probably going to require costly administrations on a continuous premise.

Notwithstanding enlisting a substantial offer of people with incessant conditions, Medicare and Medicaid's size empowers them to generally impact the human services showcase by paying more for the enlistment of individuals with more noteworthy medicinal services needs and accomplish economies of scale in executing a modification framework. Some private gathering buyers, especially bunches that buy wellbeing scope on the whole, have additionally perceived the significance of changing installments for the wellbeing and useful status of enrollees and started executing hazard balanced installments.