Introduction
It is important to note that effective organizational training strategies are critical in resolving emerging problems in a dynamic and sensitive healthcare environment. The given assessment will mainly focus on the competence of the facility’s billing and coding staff from the perspective of a director of health information at a large hospital. The core strategic procedure is comprised of four parts, which include fraudulence evaluation, anti-fraud training, program effectiveness evaluation, and criticality of information assets.
Abuse and Fraud During the Course of Medical Coding and Billing Activities
Medical coding and billing fraud can take many forms, but some common examples include upcoding, unbundling, and false billing. Upcoding is the practice of using a higher-paying code than is appropriate for the service provided, while unbundling is the practice of billing for each component of a bundled service separately (Coustasse, 2021). In addition, false billing is the practice of billing for services that were not actually provided.
An organizational policy that can help to prevent coding and billing fraud is a thorough compliance program that includes regular training for staff on proper coding and billing practices. This policy can be effective in ensuring that staff are aware of and understand proper coding and billing procedures and that they are held accountable for their actions (Taylor et al., 2021). However, it requires a culture of compliance within the organization. Another policy that can be effective is regular internal and external audits of billing and coding activities (Coustasse, 2021). This policy can be effective in detecting any potential fraud or abuse by identifying any discrepancies or anomalies in the billing and coding process. The drawback is that it can be disruptive in the operational flow of an organization, and it is most effective when done frequently.
A third policy that can be useful is the use of computerized billing systems that can help to identify and flag potential fraud or abuse. This policy can be effective in detecting any suspicious activity by comparing billing data with data from other sources, such as electronic health records, and providing alerts when certain patterns or anomalies are identified (Taylor et al., 2021). It is important to note that these policies are not mutually exclusive and work best when integrated with each other and with a culture of compliance within the organization. Additionally, even with these policies in place, it is impossible to completely eliminate the potential for fraud and abuse.
Training Programs for Medical Billing and Coding Employees
It should be noted that the new employee orientation program and ongoing training program need to be conducted separately to maximize their effectiveness. Firstly, for the former, it is critical to introduce new employees to the organization’s policies and procedures regarding medical billing and coding, including a focus on preventing upcoding, unbundling, and false billing. They should be provided with hands-on training with real-life billing and coding scenarios to help employees understand how to correctly code and bill for medical services. Instructors should review relevant laws and regulations, such as the False Claims Act and the Anti-Kickback Statute, with the new employees (Taylor et al., 2021). In addition, it is valuable to train them on the organization’s internal compliance program and the reporting mechanisms in place for employees to report any suspected fraud or abuse.
Secondly, for the ongoing training program, regularity and opportunities are vital for the existing employees. They need to be provided with frequent and periodical training sessions on updates to laws and regulations, as well as any changes to the organization’s billing and coding policies and procedures (Buljac-Samardzic et al., 2020). It requires the creation of opportunities for employees to participate in continuing education courses to stay current with the latest coding and billing practices as well. This process needs to be accompanied by regular audits of employees’ billing and coding work to identify and correct any errors or potentially fraudulent activity (Buljac-Samardzic et al., 2020). It is important for the organization to communicate that employees will be rewarded for identifying and reporting any fraudulent activities.
When it comes to the leadership approach in the implementation of these programs, it is useful to utilize a participatory leadership style. It means that the director of health information should be involved with employees in the development and implementation of the programs by making strategic alliances. The leader should establish clear lines of communication to establish structure and encourage open feedback from employees. This can boost alliance motivation, and ensure that the program outcomes are effective and meet their needs (Buljac-Samardzic et al., 2020). In addition, the director of health information should lead by example by ensuring that he or she is following all the organization’s policies and procedures regarding medical billing and coding. This means actively participating in the ongoing training program to create a culture of compliance and integrity within the organization.
An Evaluation Plan for the Training Programs
Firstly, during the pre-launch evaluation, it is critical to conduct an assessment of essential needs to determine the specific skills and knowledge that the training program is designed to address. For the methods, the management needs to develop a pre-training assessment to measure the current level of knowledge and skills of the participants (Jonden et al., 2018). It can be done by setting specific, measurable, and relevant objectives for the training program based on the needs analysis and pre-training assessment results.
Secondly, after the training programs have been launched, the efforts should focus on administering a post-training assessment following the training program to measure the change in knowledge and skills of the participants. The methods are centered around the use of a variety of evaluation methods, such as surveys, focus groups, and interviews (Jonden et al., 2018). These are necessary to gather feedback from the participants and instructors on the content, delivery, and overall effectiveness of the training program. The results of the pre-training and post-training assessments need to be compared to determine the extent to which the training program met its objectives.
Thirdly, throughout the two years of conducting training programs, periodic evaluations are essential. It is important to schedule such evaluations of the overall program at least every six months, or as often as necessary, to assess its continued effectiveness and to identify areas for improvement. The management should utilize a combination of quantitative and qualitative methods to evaluate the program’s effectiveness. The methods can include analyzing employee performance metrics and conducting interviews or focus groups with employees as well as their immediate managers (Jonden et al., 2018). In addition, it is valuable to use the information gathered from the evaluations to make adjustments to the training program as necessary and to identify areas for improvement.
Conclusion
In conclusion, the core strategic procedure consists of fraudulence evaluation, anti-fraud training, program effectiveness evaluation, and criticality of information assets. The most appropriate measures can include training, audits, and the use of technology. However, the program requires a comprehensive evaluation, such as pre-launch, post-launch, and periodic evaluations. The EDW benefits a healthcare organization by improving its decision-making, data analysis, and reporting, data security, data accessibility, as well as data quality and consistency.
References
Buljac-Samardzic, M., Doekhie, K. D., & van Wijngaarden, J. D. H. (2020). Interventions to improve team effectiveness within health care: A systematic review of the past decade. Human Resources for Health, 18(2), 1-12. Web.
Campion, T. R., Craven, C. K., Dorr, D. A., & Knosp, B. M. (2020). Understanding enterprise data warehouses to support clinical and translational research. Journal of the American Medical Informatics Association, 27(9), 1352-1358. Web.
Coustasse, A. (2021). Upcoding Medicare: Is healthcare fraud and abuse increasing? Perspectives in Health Information Management, 18(4), 1-15. Web.
Jonden, C., McCalman, J., & Bainbridge, R. (2018). Health workforce cultural competency interventions: A systematic scoping review. BMC Health Services Research, 18(232), 1-15. Web.
Taylor, D. A., Sherry, S. P., & Sing, R. F. (2021). Interventional critical care: A manual for advanced practice providers. Springer.