Claims Case Study) 1) - Microsoft Word Starter 15 ,, . cDC I Normal 1 No Space. Heading 1 Heading 2 Title Subtitle Quote Subtle Em. Emphasis Intense E. Strong Paragraph Styles Case Study: Claims Processing Source: United States Department of Health and Human Services. (2012). Review of outpatient claims processed by Wisconsin Physicians Service that included procedures for the insertion of multiple units of the same type of medical device in calendar years 2008 and 2009. BACKGROUND The Centers for Medicare and Medicaid Services (CMS) administers the Medicare program. CMS employs Medicare contractors, including Wisconsin Physicians Service (WPS), to process and pay hospital outpatient claims using the Fiscal Intermediary Shared System (FISS). CMS implemented an outpatient prospective payment system (OPPS) for hospital outpatient services. Under the OPPS, Medicare pays for hospital outpatient services on a rate-per-service basis that varies according to the assigned ambulatory payment classification group. Under the OPPS, outlier payments are available when exceptionally costly services exceed established thresholds. Common medical devices implanted during outpatient procedures include cardiac devices, joint replacement devices, and infusion pumps. Generally, a provider implants only one cardiac device during an outpatient surgical procedure. Under the OPPS, payments to hospitals for medical devices are "packaged into the payments for the procedures to insert devices. Hospitals are required to report the number of device units and related charges accurately on their claims. The failure to report device units and related charges accurately could result in incorrect outlier payments. Our audit covered $32,860 in Medicare outlier payments to hospitals for 14 claims for outpatient procedures that included the insertion of more than one of the same type of medical W . Emphasis Intense E. Strong Subtitle Subtle Em. Title 1 Normal Heading 2 | Aar := = 21 ] aby - A Em Paragraph I No Spaci... Heading 1 Styles device. The 14 claims had dates of service during calendar years (CY) 2008 and 2009. OBJECTIVE Our objective was to determine whether Medicare paid hospitals correctly for outpatient claims processed by WPS that included procedures for the insertion of multiple units of the same type of medical device. I SUMMARY OF FINDINGS Of the 14 claims that we reviewed, Medicare paid eight correctly for outpatient claims processed by WPS that included procedures for the insertion of multiple units of the same type of medical device. However, for the remaining six claims, Medicare did not pay hospitals correctly. 1 These incorrect payments were due to hospitals overstating the number of units and related charges, resulting in excessive or unwarranted outlier payments. For the six claims, WPS made overpayments to hospitals totaling $17,996. Incorrect W These incorrect payments were due to hospitals overstating the number of units and related charges, resulting in excessive or unwarranted outlier payments. For the six claims, WPS made overpayments to hospitals totaling $17,996. Incorrect payments occurred because hospitals had inadequate controls to ensure that they billed accurately for claims that included the insertion of medical devices. In addition, Medicare payment controls in the FISS were not always adequate to prevent or detect incorrect payments. CASE STUDY QUESTIONS 1. Identify and describe different types of medical claims created by healthcare providers that are submitted to insurance companies for payment. 2. Why is it important for healthcare administrators to be very familiar with the elaims process and ensure their facilities claims process is accurate and reliable? It is important for the healthcare administrators to be familiar with the claims process because these claims are what will get payment to the appropriate people. If the healthcare administrator fails to properly submit these claims or fails to appropriately complete these forms, somebody is not getting paid for their services. Even if it may seem like something minor at the time, it can all add up and become detrimental to the organization. The W 3. As an executive for the Wisconsin Physicians Service (WPS) Insurance Corporation, after reviewing the case, what recommendations would you propose to the Board of Directors that they should prepare for as a response from the Office of the Inspector General (OIG)