Overview
Part 1: Critical Analysis of the Law
Medicare is a large payer of health care services as the health care payer for the elderly.
Evaluate the Conditions of Participation (CoP) for a hospital to participate with Medicare. What are the pros and cons of a hospital being a Medicare provider? What are the consequences of non-participation with Medicare?
What is the role of the Joint Commission to obtain "deemed" status? Is Joint Commission a regulatory agency? Why or why not?
State the specific legal risks related to Medicare CoP. Discuss the COSO framework for internal controls and evaluate how it could be used to meet Medicare CoP. Be specific and demonstrate understanding of the risks and how the compliance tool can be used specifically to control the risks.
- Part 2: 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 just received notice that it will be subject to a CMS Recovery Audit Contractor (RAC) audit on the following issues and has requested medical records from your hospital and provider clinics.
0001 Inpatient Hospital MS – DRG Coding Validation
0011 Inappropriate Billing of Home Visit Professional Service Evaluation and Management Codes during Inpatient
- Name and describe the law and code section that gives CMS and RAC auditors the right to access your medical records. (Give the legal source of the right)
Discuss interoperability requirements. How do they apply to this situation? How could you prepare to have an interoperable electronic health record (EHR) that meets CMS standards? Describe the steps you would take to move towards interoperability.
Answer one of the questions.
What management actions would you take to work effectively with CMS administrators to ensure that you meet CMS CoP for Medicare?
What management actions would you take to work effectively with RAC auditors during an audit?