“The documentation, history, and trends that arise from a gap analysis process can be especially valuable for new managers” (Healthcare Financial Management Association, 2008, para. 13). As an employee of a Medicare Administrative Contractor (MAC) for the Centers for Medicare & Medicaid Services (CMS), the author will be performing a gap analysis to gain insight into claims administration. The purpose of this paper is to describe the process of interest and outline the plan for conducting a gap analysis.
Determination of Medical Necessity
Medicare benefits are issued to eligible beneficiaries through a number of Medicare Administrative Contractors (MAC). Similar to the meaningful use requirements that healthcare providers must meet, the MACs must adhere to CMS Federal Guidelines delineating the process of medical necessity determination. As noted in Review of Medical Necessity Decisions, “[The] primary expectation is based on reviewers having knowledge of Medicare coverage requirements… However, reviewers are expected to follow all applicable Medicare requirements, such as adjudication timeframes, in the performance of their duties.” (Medicare Program, 2011, p. 21496).
The current medical review process at a proprietary MAC (henceforth referred to as “Well Health”); will be reviewed for the course project. At Well Health, incoming service requests from healthcare providers are received by fax and made available to the nurse reviewers in electronic format using a computerized application. Once received by the reviewer, the nurse must access numerous web sites and programs to complete the medical necessity review process. Each of these applications is much like the standard electronic health records (EHR) utilized in many ...
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... September). A gap analysis methodology for the team software process. In Quality of Information and Communications Technology (QUATIC), 2010 Seventh International Conference on the (pp. 424-429). Retrieved from Google Scholar database.
Fater, K. H. (2013). Gap analysis: A method to assess core competency development in the curriculum. Nursing Education Perspectives, 34(2), 101-5. Retrieved from http://search.proquest.com/docview/1350295201?accountid=14872
Healthcare Financial Management Association (HFMA). (2008). Gap analysis helps nurses become better leaders. Retrieved from http://www.hfma.org/Content.aspx?id=3398
Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs for Contract Year 2012 and Other Changes, 76 Fed. Reg. 21495 (April 15, 2011) (to be codified at 42 C.F.R pt. 422.562, 422.566, 423.562, & 423.566).
The adoption of clinical information systems is one way that healthcare organizations are making an effort to improve patient safety, provide a means to exemplify regulatory compliance, and facilitate exchange of patient information between care providers (Kirkley & Stein, 2004; Nadzam, 2009). To achieve this goal, Barnes-Jewish Hospital (BJH) recently implemented a new CPOE/clinical documentation system. One of the objectives of the new system was to give bedside clinicians a standardized electronic tool, known as the Clinical Summary, for bedside shift hand-off reporting. Soon after go-live, it was identified that the standard nursing Clinical Summary did not meet specialized the reporting needs of the nurses on the Women and Infants divisions. Consequently, an application enhancement request was submitted. The goal of this project is to synthesize the knowledge gained throughout this Masters Degree program to initiate, plan, and execute changes to the current clinical documentation system to provide a standardized Clinical Summary review screen to meet the specialized hand-off reporting needs of the nurses on the Women and Infants divisions at BJH. This paper includes project objectives, a supporting evidence-based literature review, project methodology, formative and summative evaluation criteria, and a graphical timeline with a narrative description for the Women and Infants Clinical Summary project.
To guarantee that its members receive appropriate, high level quality care in a cost-effective manner, each managed care organization (MCO) tailors its networks according to the characteristics of the providers, consumers, and competitors in a specific market. Other considerations for creating the network are the managed care organization's own goals for quality, accessibility, cost savings, and member satisfaction. Strategic planning for networks is a continuing process. In addition to an initial evaluation of its markets and goals, the managed care organization must periodically reevaluate its target markets and objectives. After reviewing the markets, then the organization must modify its network strategies accordingly to remain competitive in the rapidly changing healthcare industry. Coventry Health Care, Inc and its affiliated companies recognize the importance of developing and managing an adequate network of qualified providers to serve the need of customers and enrolled members (Coventry Health Care Intranet, Creasy and Spath, http://cvtynet/ ). "A central goal of managed care is containing the costs of delivering care, but the wide variety of organizations typically lumped together under the umbrella of managed care pursue this goal using combination of numerous strategies that vary from market to market and from organization to organization" (Baker , 2000, p.2).
This is a critical review of the article entitled “Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care”. In this article, Lundberg, C.B. et al. review the different standardized terminology in electronic health records (EHR) used by nurses to share medical information to the rest of the care team. It aims at showing that due to the importance of nursing in patient care, there is a great need for a means to represent information in a way that all the members of the multidisciplinary medical team can accurately understand. This standardization varies from organization to organization as the terminologies change with respect to their specialized needs.
Baker, J. J. & Baker, R. W. (2014). Health care finance Basic tools for nonfinancial managers (4th ed.). Burlington, MA: Jones & Bartlett Learning
Historically, physicians and nurses documented patients’ health information using paper and pencil. This documentation created numerous errors in patients’ medical records. Patient information became lost or destroyed, medication errors occur daily because of illegible handwriting, and patients had to wait long periods to have access to their medical records. Since then technology has changed the way nurses and health care providers care for their patients. Documentation of patient care has moved to an electronic heath care system in which facilities around the world implement electronic health care systems. Electronic health records (EHR) is defined as a longitudinal electronic record of
Senior nursing students will complete a QSEN weekly clinical journal requirement learn how to self-assess their progress toward demonstrating these nationally-based competencies. The students will select a different competency each week to address and discuss how they applied that competency to patient care or how they hope to better achieve that competency as a graduate nurse. By the end of the clinical rotation each student will have had a chance to focus on each of the six QSEN competencies: patient centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety and informatics. The students’ reflection on their clinical experiences each week will teach them how to integrate the core competencies required before graduation. According to Use of self-evaluative practices puts the power back upon the student to direct and think critically about their learning (Dickensen, 2015). Demonstrating these competencies supports safety and excellence in clinical practice (QSEN,
Theisen, J. L., & Sandau, K. E. (2013). Competency of new graduate nurses: A review of their weaknesses and strategies for success. Journal of Continuing Education in Nursing, 44(9), 406. doi:10.3928/00220124-20130617-38
§§ 413.20. By applying the above rule to the issue at question, application of GAAP is required only for reporting purposes and not for Medicare reimbursement determination. Hence, 42 C.F.R. § 413.20 requires providers to report their costs in accordance with GAAP, it does not require costs to be reimbursed in the year that they are reported. In other words, the regulation instructs the Secretary to establish methods for determining cost reimbursement. Therefore, cost reimbursement determination is established by the guidelines that are promulgated by the Secretary of HHS i.e. PRM §233. The Secretary’s guideline PRM §233 requiring that the costs are spread over a period of years is a reasonable implementation of the Secretary’s duty to avoid distortions in the reimbursement process. The Supreme Court of the U.S. decided that the defeasance losses should be
Nursing practice holds different levels of degree for nurses that include Associate degree in Nursing, Bachelor degree in nursing, and Master degree in Nursing. Even though the degree level in nursing are to provide basic care to the patients, but the level of competency and knowledge in the profession is different. Nursing practice in advance level play important role to provide quality of care to patients. Many health care settings require nurses to earn baccalaureate degree level to apply for RN position. The purpose of writing this paper is to identify the proficiency level between an Associate degree of Nursing versus Baccalaureate degree level.
In analyzing the internal environment within the claim review team at Optum, an assessment of the department, organization, and team was conducted utilizing the outcome improvement readiness assessment (HealthCatalyst,
There are four components to the Medicare program, part A, B, C and D. Part A of Medicare covers in patient hospital services; patients have a financial responsibility to cover a deductible that is equivalent to 1 day of hospitalization, thereafter cost is covered at 100 percent for a maximum of 60 days. This also includes nursing facilities, home and hospice care. Part B covers outpatient surgery and physician office visits. This is an elective component of Medicare in that there is a premium associated with this plan that is paid for directly through social security payments. Part C is know as Medicare Advantage and is a supplemental policy that is purchased directly from employers; one may be denied for health reasons depending one when the plan is acquired. Part D is prescription drug coverage that is eligible to all individuals that qualify for Medicare. Beneficiaries of the Medicare choose which prescription plan they want and pay a corresponding monthly premium.
In 1990 a group of educators, called the National Task Force for Family Nurse Practitioner Curriculum and Evaluation, created the initial curriculum guidelines for nurse practitioners (Graduate nurse practitioners education competencies, n.d.).Today, the NONPF represents most NP educational institutions worldwide and they continue to develop/improve the NP competencies and guidelines in order to prepare healthcare professionals across the world (Graduate nurse practitioners education competencies,
It is well known that the team work is far better than performing a task individually. Such kind of practice plays a very important role in software engineering. A lot of things can be achieved together with the combination of diversified people, as they input different tactics and skills so that the main objective of a certain mission can be accomplished appropriately. Even though teaming up and working for a project is essential and helpful; there exist some issues that could bring interruptions and conflicts in the team.
Also, these studies question those who are effected; in this case, those who are most effected, is everyone. Doctors and nurses spend the most time working within these systems, but the information that is put into these systems effects every individual in America, because it is their information. Because nurses are often considered “both coordinators and providers of patient care” and they “attend to the whole patient,” their opinion is highly regarded (Otieno, Toyama, Asonuma, Kanai-Pak, & Naitoh, 2007, p. 210). It is clear that the use of these new systems is much debated, and many people have their own, individualized opinion. This information suggests that when there is a problem in the medical field, those who address it attempt to gather opinions from everyone who is involved before proceeding. It has been proven by multiple studies that this system of record keeping does in fact have potential to significantly improve patient health through efficiency, and it is because of this that the majority of hospitals have already completed, or begun the transfer from paperless to electronic (Otieno, Toyama, Asonuma, Kanai-Pak, & Naitoh,
It is important that students have the ability of being competent in a clinical setting. To be deemed competent in skills according to nursing regulations and requirements. This is a challenging factor for many students, as they enter transition period. This is due to students feel they do not have the desired clinical competency that promotes the skills and authorities of a registered nurse (Harsin, Soroor & Soodabeh, 2012). Clinical research studies have found that students do have the required expected levels of knowledge, attitude and behaviour’s. However, the range of practical skills aren’t sufficient for the range of practice settings (Evans, 2008). This research has also found that other evidenced based studies found that competency in nursing skills is still lacking (Evans, 2008). These skills are lacked by students and newly graduated nursing how are in the first or second year of