You are the compliance officer at the hospital in the case below. Discuss your concerns, if any. Then discuss how you might address the issue. Three years ago, when Suburban Hospital found itself in financial trouble, it hired Allan Hale as a senior administrator on the basis of his experience in revitalizing a large health care corporation. In reviewing hospital billing practices, Hale immediately noticed that the coding of a given medical condition significantly affected reimbursement. He instituted new policy such that, whenever there was an ambiguity in a patient's diagnosis, clerks would enter the most remunerative code possible. Hale has also found the billing department too cautious in its reimbursement claims for expenses such as interest charges for the facilities under Medicaid and Medicare programs. He has directed that whenever there is any doubt, staff should claim the maximum amount. As a realist, however, he has instructed accounting personnel to develop two financial plans: one to incorporate the reimbursements claimed under the aggressive approach, and the second to assume that many of those claims will be disallowed.
You are the compliance officer at the hospital in the case below. Discuss your concerns, if any. Then discuss how you might address the issue.
Three years ago, when Suburban Hospital found itself in financial trouble, it hired Allan Hale as a senior administrator on the basis of his experience in revitalizing a large health care corporation. In reviewing hospital billing practices, Hale immediately noticed that the coding of a given medical condition significantly affected reimbursement. He instituted new policy such that, whenever there was an ambiguity in a patient's diagnosis, clerks would enter the most remunerative code possible.
Hale has also found the billing department too cautious in its reimbursement claims for expenses such as interest charges for the facilities under Medicaid and Medicare programs. He has directed that whenever there is any doubt, staff should claim the maximum amount. As a realist, however, he has instructed accounting personnel to develop two financial plans: one to incorporate the reimbursements claimed under the aggressive approach, and the second to assume that many of those claims will be disallowed.
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