You have been hired as the chief compliance officer at Medical Center. The Medical Center has received 100 denials for inpatient medical necessity from Medicare in just the past few months. You have reviewed the records as well as the appeal letters that were submitted previously, which resulted in 56 of the cases being overturned on appeal (this means that 44% were denied). Two physicians are noted to have 18 of the 44 denied cases, but the remainder come from a variety of physicians and services. Note that these two physicians admit many patients to UCF Medical Center.
Plan a corrective action plan for EACH of the following three areas of concern and note that each area should be addressed with one hundred words. Ten points per plan. Each plan must include who should be involved (be as specific as possible). Keep in mind that HIM professionals must work with other hospital personnel to solve these issues (including medical staff [physicians]) but everyone does not need to be involved in each issue. Actually, its possible that other department heads should take the lead on one or more of the issues! It is important for you to understand the roles that various people in healthcare perform so think about this carefully as you develop the corrective plans for the Medical Center. Discuss meetings to be held, processes to be changed, continuing education/training that may be required, etc. How will you handle the two physicians who have numerous denials (ten points), thinking about this in terms of credentialing and privileging (refer back to Martin Memorial Medical Staff requirements [Credentialing], the legal cases and the credentialing assignment for ideas), and keeping in mind that both of these physicians admit many patients to the Medical Center.
Failure to issue Advanced Beneficiary Notice for inpatient procedure/service: 3 cases
Patient admitted to inpatient status rather than observation: 9 cases
Lack of inpatient medical necessity/inadequate documentation: 88 cases
