Debbie Smith is a Medicare patient that presents to your facility today for a complicated expensive medical procedure that is not covered by Medicare. Your facility had prior knowledge of the non-coverage of this procedure and demands full payment from Debbie when she presents at the admissions department. Upon finding out that Medicare does not cover this procedure Debbie is upset and angrily informs the Director of Admissions that she will be filing a complaint because nobody informed her of the non-coverage. You are the Assistant Compliance Manager and you are responsible for addressing Debbie’s complaint. Upon investigating Debbie’s claim of non-notification you find that indeed she was provided no notification of non-coverage. You now need to determine what risk your organization has and determine what your next steps should be to ensure that this never happens again.
For this assignment develop an assessment of what risks your organization now faces if Debbie files a complaint. Define what penalties might be imposed if her claims are supported.
Define what the process should have been to inform Debbie of her coverage determinations. Compose a detailed write up of what Debbie’s experience throughout should be using the information above and integrating the following terms within the scenario so the reader will understand the meaning of the term and how it applied to her experience. Review this experience from the point of view of an inpatient, outpatient, and physician office setting
- EOB
- ABN
- Electronic data interchange (EDI)
- HIPAA
- HIPAA 5010 transaction code set (or other ANSI standards)
- Coding
- Chargemaster
- Bill reconciliation process
Your scenario should be no longer than two pages in length and can include other details and terminology as desired.