For this assignment discussion board, you will be selecting a specialty drug to research and share with the class.? After selecting a specialty drug, answe

Scenario: You have been hired as the chief compliance officer at Mercy West Medical Center. Over the past few months, Mercy West has received a high number of denials for inpatient medical necessity from Medicare. You conduct a review of the most recent 100 denials.

After reviewing the records and appeal letters, you find that 56 of the 100 cases were overturned on appeal – this means that 44 were denied even after appeal. Two physicians are noted to have 23 of the 44 denied cases, and the remainder come from various physicians and services. These two physicians have been practicing at Mercy West for 20+ years each, are resistant to change and technology, and admit many patients. There are three main areas of concern:

1.Failure to issue Advanced Beneficiary Notice for inpatient procedure/service: 7 cases

2.Patient admitted to inpatient status rather than observation: 12 cases

3.Lack of inpatient medical necessity/inadequate documentation: 81 cases

Directions:

You will create a corrective action plan for each of the three areas of concern using the provided  template  Download template . Your plan should be professional, detailed, and concise (300-600 words total; 100-200 words per issue; you will lose points if you do not meet OR you exceed this word count). After completing your action plan, format the table to be ready for presentation (consistent headings, font size, resize columns to fit text, etc.).

Your plan should address:

· Who should be involved (be as specific as possible)

· Remember that HIM professionals must work with other hospital personnel to solve these issues (including medical staff), but everyone does not need to be involved in each issue. Along the same lines, the same personnel should not be responsible for all issues. Other department heads should take the lead on one or more of the issues! It is important for you to consider the roles that various people in healthcare perform when developing your action plan – this may require additional research if you are unfamiliar with the typical hospital structure.

· Meetings to be held

· Details of an initial meeting (who should attend, the main objective, etc.)

· Plans for follow-up meetings (who should attend, how often, etc.)

· Processes that need to be changed (be as specific as possible)

· Consider the processes involved in completing the functions associated with each issue

· Continuing education/training

· How often, who is the training for, etc.

Extra Credit (+5 points):

How will you handle the two physicians who have numerous denials? Think about this in terms of credentialing and privileging – keep in mind that both of these physicians admit many patients to the Medical Center. Create an action plan for the two physicians using the assignment template.

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Corrective Action Plan Mercy West Medical Center

Identified Issues	Responsible Party/Parties	Meetings	Processes to Be Changed	Continuing Education/Training
Failure to issue ABN
Admitting to inpatient status vs. observation
Lack of inpatient medical necessity/inadequate documentation
Two problem physicians