Policies, procedures, and regulations form the guidelines for work in the organization. The healthcare facilities are not different from the others. They require specific action plans to guide the employees in their service delivery. The presence of the policies acts as a deterrence to the errant employees who might take advantage and do what is not expected of them. On the other hand, the lack of an action plan offers a chance for the employees to exercise their wishes. The lack of adequate policies creates a loophole for some of the employees to exercise fraudulent activities thus exposing the organization to risk. As a health executive, it is expected that one will lay down the specific procedures to monitor the possibility of fraudulent activities and also assess the effectiveness of the policies and procedures applied. The programs need to be determined, implemented, and evaluated to ensure that everything falls into place as expected (Cancedda et al, 2015). Every step of the systems and the implementation of the procedures is as important as the organization as a while.
Part 1
Policies to monitor abuses and fraudulent trends
Types of abuse and fraud in medical billing and coding activities
Collusion with the insurance companies: the billers and the coders may take advantage and cooperate with the insurance company at the expense of the patient. The patient may, therefore, end up getting less than he or she ought to receive as compensation from the company as some of the amounts will be taken up through fraud by the parties involved.
Collusion with the patient: the billers may also cooperate with the patient to provide fake information to the insurance companies (Humphreys et al 2017). The patient will then be paid more than the health situation calls for thus profiting the patient as well as the medical billers.
Falsified information: for no apparent reason, the medical billers and coders may find it tiresome to trace the medical history of the patients. For this reason, they might decide to cook figures and information and forward it to the insurance company. As a result, the wrong information will be taken up by the insurance company, which is against the principles of insurance that call for utmost faithfulness.
Organizational policies and procedures to monitor such fraud and abuse
Supervision: the billers and the coders could be supervised as they do their job. Having a supervisor keeping an eye on the billers will prevent any form of fraud from being implemented. This could only be possible where the collision occurs.
Continuous assessment: a continuous evaluation ought to be done on the records maintained by the billers and coders. This could be done efficiently through surprise checks in which case the health executive determines how accurate the information provided by the billers is.
Insurer-company partnership: the healthcare facility could maintain a close relationship with the insurance company. This would require the medical billers and coders to provide information bit by bit and from time to time. This would serve as an excellent forum for accurate information as opposed to the provision of bulk information all at once. Giving of bulk information creates loopholes for the billers to provide false information and thus induces unnoticed fraud.
Part 2
Staff orientation and training programs
Medical billers’ independence training program
Part 1 presents that some of the medical coders and billers could collude with the insurance companies to defraud the patient. In this case, the medical billers need the skills and knowledge on the need to remain indolent at all times and thus avoid the influence of the company. The training program will, therefore, entail the dangers of conspiring with the insurer at the expense of the patient. The training will also offer information on the consequences that would face an employee who goes against the expected conduct and conspires with the insurer. A charismatic form of leadership will be used to plead with the employees to refrain from such fraudulent activities.
The need for a confidentiality program
With the collusion form of fraud presented above, the medical billers show a lack of conscience in the maintenance of patients’ information. Therefore, the training will offer knowledge relating to the importance of maintaining a high level of confidentiality of the patient’s information. The consequences that result from lack of confidentiality in the patient’s information will also be offered during the training. A charismatic form of leadership will be suitable for this training program to have the billers and coders comply with the need for confidentiality.
Responding to fraud coercion cases program
In many cases, the billers and the coders are pushed to engage in such fraudulent acts. This is not expected to end soon as many third parties are interested in the affairs of the healthcare facilities as well as the insurance policies paid for by the patients. As such, the training program will offer the necessary information on the issues to illustrating fraud. The training will ensure that the employees can readily detect undue influence in the scam and thus refrain from it immediately. The leadership style that could be used in offering the training to the employees is transformational leadership. Transformational leadership ensures that changes are attained efficiently in the organization (Freeman et al, 2014). It, therefore, serves the best in that it changes the mindset of the billers and coders concerning the possibility of fraud.
Part 3
Evaluation of initial and continuous programs
Various methods could be used to determine the effectiveness of each of the programs mentioned above. In this case, all the methods apply to all the aforementioned training programs depending on the timing. The various methods include:
Assessment of the skills method
The health executive could offer the tests of the evaluation to the different medical billers and coders from time to time. The assessment tests are fit in the assessment of the initial programs as well as the continuous forms of training. They provide a good chance for the employees show what they well understood and what did not get into them. Therefore, they offer a platform for the improvement of the training programs.
Social ownership method
The employees are first trained by the experts and thus get information as fresh as it lands. A useful assessment of the competency of the trainees could be determined by their ability to teach each other. The evaluation, therefore, revolves around the possibility of peer teaching from time to time. A training program that enables the billers and coders to train each other on similar areas of concern proves to be useful and vice versa.
Visual confirmation method
The visual confirmation approach allows the trainees to take the training a step further without the help of the trainer. Where the trainees can train further on their own, the program proves to be effective. On the other hand, where the trainees stick to the content of the trainer and are unable to move further on their own demonstrates that the training is wanting. Where the assessment indicates a weakness in the form of training, restructuring is needed to have the best from the practice.
Part 4
Facilitating the use of enterprise assets in support of strategic objectives
Various assets promote the attainment of the strategic goals of the organization. The effectiveness of the achievement of the set strategic purpose relies on the available assets as well as the efficiency of their use. EDW forms part of the significant assets of the organization, and this means a lot in the attainment of the strategic objectives.
Benefits of EDW to a healthcare facility
Vast information: the EDW acts as storage for a large amount of data affecting the healthcare facility. The EDW contains the patients’ historical information as well as medical details. Also, all the stakeholders’ information is contained there thus offering an excellent source of the same when required.
Easy access to information: the EDW ensures that data is accessed reliably whenever it is needed. The users can get the information as it is not easily lost.
Fewer disputes: as the information is easily accessed, the possibility of conflicts from the loss of data is reduced. The operation of the healthcare facility, therefore, becomes better and smooth for the overall management.
Strategic objectives
To reduce patient complaints by 10%: easy access to the information regarding the patients offers a good chance to minimize the complaints from them. The information contained elaborates on the respective needs of each of the patients. As a result, better services ware offered to lead to a reduction in the level of patient’s complaints.
To increase the service delivery speed by 0.25 rate: the information contained in the EDW makes its aces easy. Therefore, the healthcare facility would aim to increase the service delivery to the patients. The patients ought to be treated at a faster rate and thus have their level of satisfaction improved (Dawson et al, 2015). The healthcare facility aims at serving more customers at a time.
Information assets
Personal health records: the records are assets that could be efficiently used to offer the respective treatment required by the patient. Having this in the EDW will help in the attainment of faster service delivery to the patients.
Clinical automation systems: such assets will also ensure that the patient’s information is shared among the relevant stakeholders in real-time. Thus, the patients will be attended to as soon as they need it. The effect would be the minimization of the level of patients’ complaints, especially those hailing from delayed treatment.
References
Cancedda, C., Farmer, P. E., Kerry, V., Nuthulaganti, T., Scott, K. W., Goosby, E., & Binagwaho, A. (2015). Maximizing the impact of training initiatives for health professionals in low-income countries: frameworks, challenges, and best practices. PLoS medicine, 12(6), e1001840.
Dawson, A. J., Nkowane, A. M., & Whelan, A. (2015). Approaches to improving the contribution of the nursing and midwifery workforce to increasing universal access to primary health care for vulnerable populations: a systematic review. Human resources for health, 13(1), 97.
Freeman, T., Edwards, T., Baum, F., Lawless, A., Jolley, G., Javanparast, S., & Francis, T. (2014). Cultural respect strategies in Australian Aboriginal primary health care services: beyond education and training of practitioners. Australian and New Zealand journal of public health, 38(4), 355-361.
Humphreys, J., Wakerman, J., Pashen, D., & Buykx, P. (2017). Retention strategies and incentives for health workers in rural and remote areas: what works?.
