Question

1) Discuss the effects of: a. upcoding, b. downcoding. (IX.C.4

2) Outline managed care requirements for patient referral. (VIII.C.2)

Answer 1

Ans 1.a)Effects of Upcoding:- Effects of upcoding include higher medical costs for tax payers and the insured.it can have negative health ramifications for patients.it pouts false information on their medical records and can affect their future ability to get insurance.Both down coding and upcoding are illegal practices and medical assistants can be prosecuted for either practice.

b)Effects of Down coding:-Effects of Insurance carriers always downcode.Codes are ambiguous and reimburse the provider for the lowest possible fee.If Workers Compensation claims examiner has to convert a CPT code to a relative value scale,the examiner will select the lowest paying code.When attached documentation does not match the written description of the procedure,the reimbursement will always be the lowest paying code.

• Downcoding affects our consumers badly and reduces their profits. Unique Medical Billers and Coders always avoid the falsehoods that surround this common practice.

• It has an effect on more than just profits. Compared to upcoding, it has the same and sometimes even greater level of impact on regulation and audits.

• It can seem like a simple thing, but if a patient moves to another provider for intensive care, downcoding providers can face lawsuits for unethical medical practices.

• Because of down coding, many companies suffered extreme layoffs. The alternative is to report quality care if you’re trying to avoid audits.

2.The term managed care or managed healthcare is used in the United States to describe a group of activities intended to reduce the cost of providing for-profit health care and providing American health insurance while improving the quality of that care ("managed care techniques").

it intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as Health Maintenance Organizations and Preferred Provider Organizations.