Using Gap Analysis to Understand and Improve Healthcare Delivery Practices

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“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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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).

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