Week #5-To Do List-CCHWeek 5 IntroductionIntroduction To Co.docx

Week #5-To Do List-CCH
Week 5: Introduction
Introduction To Compliance Documentation & Reporting
Proper documentation is an inherent component of delivery of
care, not an add-on. One of the oldest battles in healthcare is
that between the hospital Medical Records department and the
admitting Physician to complete necessary documentation for
the Patient’s Chart. The most common cause of loss of
admitting privileges has been from this source. This process
has only become more important and necessary with the
increasing recognition of the importance of proper
documentation for legal and ethical defense purposes.
Documentation also serves a number of financial aspects of
patient care delivery, including billing, grant writing for
research projects, medical research to discover future tests,
procedures, and cures, and funding for government supported
agencies and programs.
Objectives
To successfully complete this learning unit, you will be
expected to:
Identify the uses for health care documentation.
Learn the essential components of quality documentation.
Categorize the document guidelines under the federal False
Claims Act.
Identify the documentation required for compliance under the
Federal Stark Law.
List the aspects of documentation compliance with regard to
electronic health records.
Identify the important issues regarding ethical coding
practices.
Learn the most common illegal practices for HIM reporting.
Identify the key concerns under the federal False Claims Act
that relate to reporting.

Determine the impact of the Physician Quality Reporting
Initiative (PQRI) on HIM processes in physicians’ offices.
Identify the circumstances in which a health care
professional is mandated to report a patient’s diagnosis.
Week 5: Discussion
Answer the following questions:
Review the various uses for health care documentation and
discuss how each has an impact on the health care delivery
system
Discuss procedures you might enact in your facility to avoid
violating the False Claims Act
Discuss why physician offices should participate in PQRI
Week 5: Case Study Assignment
Please read and choose one of the following case studies:
Case study on page 111 of your textbook. (This Case Study is
in the section for Securing EHR and starts with "NOTE: In each
CMP (Civil Monetary Penalties) case resolved through a
settlement agreement, . . . ")
in the section for Phantom Patients and starts with "Two
Charged in False Claims to Medicaid."
in the section for Services not Performed and starts with
"WASHINGTON—April 14, 2008—A board-certified
radiologist, Fred Steinberg, M.D., his imaging centers . . ."
in the section for Upcoding and starts with "July 2007: In
Florida, a doctor was sentenced to 78 months in prison and
ordered to pay $504,000 . . . "
in the section for DRG Creep and starts with "In a report from
the Office of the Inspector General, with recommendations

regarding the evidence of upcoding DRGs by hospitals:"
in the section for Misuse of Modifiers 25 and 59 and starts with
" Findings: Forty percent of code pairs billed with Modifier 59
in FY 2003 did not meet program requirements, resulting in $59
million in improper payments."
in the section for Qui Tam and starts with "New Jersey Hospital
Company Settles Qui Tam Lawsuit Alleging Medicare Fraud for
$256 million."
Provide an explanation for the choice you made. Your paper
must address the following:
Address problem of the case decision.
A thorough analysis including resources.
Detailed comprehensive realistic recommendation.
Supplements with extensive compelling evidence from
legitimate sources.
Sources cited correctly in the body of the case and reference
page.
***PLEASECHOOSE ONE OF THE CASE STUDIES FROM
ABOVE SO THAT I CAN TYPE OUR FOR YOU FROM THE
TEXT***
Market Structure and Pricing Power
1
2

Hiara Custodio
University of Phoenix
Professor

Introduction
A Recent report by the Center for Disease Control showed
that 65 % of all Americans have a cover under the private
insurance. There are specific public programs that complement
the services provided by the private health industry. Public
programs include social insurance for the disabled, Medicare,
and Medicaid.
The federal government in conjunction with state governments
funds the programs. Private health insurance in the United
States forms a fundamental in the country`s health care
industry. Most Americans have taken medical cover under the
private insurance system.
Market Structure
An oligopoly is a distinct market structure where only a
few firms have overshadowed others and take a huge market
share. Very few firms dominate, though the market presence of
other small players may exist. The market, in this case, is
communally jointed to a few firms, and it is thus competitive.
For the case of United States, major health care insurances such
as Aetna and Anthem operate with minimal competition.

However, there are many smaller independent plans dedicated to
physically challenged people to offer specialty services. An
example of an insurance service that has dominated this market
is the Blue shield blue cross Permanente insurance plan.
The program evolved from Blue shield blue cross industrial
companies and was later on listed for public enrollment. It is
important to examine outcomes of different quality measures on
the demand for insurance products in the market.
Hypothetical analysis of the plan
The plan will use some variables as controls. The value of
this plan will increase as a number of people enrolled increases.
The program type variables are PPO and HMO, and both of
them offer broad networks. The two plans are relatively not
communicated within the consumer base, so many enrollees may
show less familiarity. Deductibles and out of pocket expenses
significantly limit changes. The variations have an influence on
demand. A deductible has to be paid before actual coverage,
hence high deductibles are much undesirable. Patients will
prefer plans that have some form of cost limit and have lower
deductibles. Research has shown that plans that have a
significant number of plan offerings will always hold better
value in the market.
Elasticity of the insurance offered
In estimating the elasticity of the insurance service, there
are several key approaches that researchers can adopt. The most
significant method is through the application of distinctions on
the premiums in a bid to identify the price consideration that
was taken into account. Alternatively, the researchers can use
distinctions in tax ratios over states as a means of recognizing
price elasticity in the insurance.
Most insurance plans contain many features that affect the
payment by consumers, and they may also undergo changes. The
out of pocket pay benefits are of particular importance in the
markets where minor beneficiaries are enrolled into zero-

premium plans. In this way, a large portion of the beneficiaries
income will be spent on the out of pocket pay.
The demand has shown that the out of pocket pay may
present particular importance in relation to the surplus. There is
a difference between the amount paid to different plans
countrywide. The government has a payment plan that gives
health maintenance organization (HMO) plans more pay than
the traditional Medicare. The PPO plan receives the highest
amongst the plans. The demand for insurance is elastic since an
increase in prices would lead to a decrease in number of
subscribers (McCanne, 2010). An example is when HMO plan
raises its prices. The effects are that they will lose customers
and subsequently lose on profit generation. Elastic demand has
helped shaped the industry and has motivated more firms to
reduce the price.
Marginal Cost and Marginal Revenue
Marginal revenue as a statistic is calculated by dividing
the difference in total revenue by the quantity change in output.
It is clear that the marginal revenue tends to remain steady over
a specific level of the production. The marginal revenue will
then follow the law of decreasing returns so that it shows delay
at some point. With increase in output, the health insurance
firms require an increase in fees charged. The perfectly
competitive companies will continue production until when the
marginal revenue will equal the marginal cost. In case the
marginal revenue exceeds the marginal cost, the HMO will have
an opportunity to increase profits by cutting the prices. The
lower prices will attract more subscribers and generate large
revenue.
Strategies for developing product differentiation and market

segmentation
Oligopolies have a definite advantage in the market and
maintain a large market share. Their level of dominance makes
it very costly for any rival wishing to capture their market
share. The market presents many barriers to new entrants. In
most cases, the incumbent in the market are continually
developing strategies that will keep out any invading
competition (Matthews, 2010). The insurance firms in this
market can adopt a non-price strategy.
It is the most convenient since price competition will form a
very destructive force. They will only have to seek consumer
interest through sales promotions or offering low premiums.
Loyalty schemes are an alternative non-pricing strategy in the
insurance sector.
Alteration of fixed and variable cost to support the strategy
Mixed costs refer to costs that are directly connected to the
product, and it has to be paid regardless of the amount sold. As
for the fixed cost, they must be paid at the end of every month.
In cases where consumers fail to purchase insurance plans, the
company will still have to pay the physicians and staff. Variable
costs changes with the amount of sold. The strategy will
incorporate the variable cost factor by increasing plan premiums
when consumers purchase more plans. Variable costs relate to
materials and labor, which fluctuates with time.

Conclusion
Oligopolies have a tendency to implement very
competitive approaches. There is a trend towards designing
their strategies in ways that create advantages that are present
in the more competitive market structures. Due to the fact that
there are very few number of companies operating in the
market, the firms have to implement marketing techniques that
bring higher competitiveness. Oligopolists have shown
dominance in the innovation of new products (Sonnenholzner,
2006).
The super profits they generate are useful in revolutionizing the
sector, hence improved performance. Application of the
described models will result in economic stability of the sector.
Price stability will further benefit the consumers since they can
easily plan ahead. Consumers that have a well-laid out plan
have increased chances of controlling their expenses, which will
increase the probability of them subscribing to insurance
policies. Approaches that focus on the consumers will increase
the number of subscribers and subsequently benefit the entire
health insurance industry.

References
Investopedia. (n.d.). Oligopoly Definition | Investopedia.
Retrieved April 18, 2016, from
http://www.investopedia.com/terms/o/oligopoly.asp
Matthews, M. (2010, June 7). America's Coming Health Care
Oligopoly. Retrieved April 18, 2016, from
http://www.forbes.com/2010/07/07/healthcare-reform-
insurance-hospitals-contributors-merrill-matthews-
obamacare.html
McCanne, D. (2010, June 25). The private insurance oligopoly -
PNHP's Official Blog. Retrieved April 18, 2016, from
http://pnhp.org/blog/2010/06/25/the-private-insurance-
oligopoly/
Sonnenholzner, M. (2006, September 13). Oligopoly in
Insurance Markets - Encyclopedia of Actuarial Science -
Sonnenholzner - Wiley Online Library. Retrieved April 18,
2016, from
http://onlinelibrary.wiley.com/doi/10.1002/9780470012505.tao0
03/abstract
MHCM 6320 Corporate Compliance and Legal Issues in
Healthcare
Chapter 6 Compliance Documentation
Chapter 7 Compliance Reporting
Week 5 Lecture Notes

It is important that the compliance program highlight this
requirement for adequate
documentation of all aspects of patient care delivery. The
documentation serves a
number of valuable purposes, besides the requirements of
compliance. Specifically, it
provides support for medical decision making, provides for
continuity of patient care,
supports patient and public safety, assists in the allocation of
resources, supports
research and education, and finally provides evidence of
compliance. Good
documentation also contributes to quality improvement
programs and supplies
necessary information to proper payment/reimbursement.
In order for documentation to serve all of these aspects of
patient care well, it must be
complete, accurate, timely and accessible. It should always be
signed or otherwise
confirmed.
A growing practice that presents considerable danger in any
documentation is the

practice of excessive abbreviations or use of mnemonics,
acronyms, symbols or other
shortcuts in word usage. This is a dangerous practice
throughout our culture,
aggravated by the use of texting and email as well as the
generally sloppy use of
language. No abbreviation should be used in a document
without first using the full
word or phrase to be represented by the shortened version.
Unfortunately, many
abbreviations have “twins” with totally different meanings, and
this can lead to
misunderstanding at the least and disaster at the greatest. This
problem has reached
the point that some organizations have published “Do Not Use”
lists of such
abbreviations.
The False Claims Act sets out specific elements for
documentation compliance.
According to the Act, patient records must be complete and
specific with regard to
medical necessity, certification of medical necessity, refunding
of overpayments,

contractual agreements with billing service companies, release
of information regarding
reimbursement, diagnostic X-Ray interpretation, certification of
compliance, dates of
service, and claims support.
The Federal Stark Law, which is reinforced or expanded by
many state laws, forbids a
referring physician from financial gain when referring a patient
to another physician –
usually a specialist, when the patient is a Medicare or Medicaid
beneficiary. This rule is
applied across a broad spectrum of referral situations and is not
restricted to only
physician to physician referrals, but includes referrals to
organizations or companies in
which the referring physician may hold an interest and therefore
benefit from the
revenue or any other benefit generated from the referral.
There is also federal legislation known as the Federal Anti-
Kickback Statute that makes

it a crime to exchange any type of benefit for a referral. This is
broader than the Stark
Law in that no involvement of Medicare or Medicaid is required
to be in violation.
There are certain required elements of documentation for
physicians in every patient
encounter. These elements must always be present: the date;
the patient identity; a
unique identifier for the patient; the identity of the provider; the
reason for the encounter;
details of all communications; details of any examination/s;
objective findings; complete
description of all services performed; follow-up orders;
provider’s signature.
Hospitals have an additional set of documentation requirements,
and these were
expanded in 2007 when the CMS mandated that hospitals report
those conditions
identified for each patient that were present at the time of
admission. There are also
specific requirements for documentation of physician’s notes in
the patient’s record.

Electronic Health Records (EHR) are finally becoming a reality.
Your instructor was
President of one of the three first companies in the United
States to develop total
hospital information systems (THIS), in the late 1960s-
specifically beginning in 1967. It
was an element of these early systems to produce an electronic
patient record as a by-
product of the use of these computer driven communication and
data collection systems
by capturing the medical information at the source and
processing it and recording it to
the finish. Unfortunately, the road has been very long and
frustrating and fraught with
not only technological difficulties but with patient care
deliverers resistance to change.
In 2004, President George W. Bush set a goal for
implementation of the electronic
health record by 2014. While that goal too has failed to be met,
progress has now been
great and the end result is definitely in sight.
As the dream becomes a reality, it is vital that the compliance
officer work with the

technology department to ensure that such a record be kept
secure. It is necessary to
assure the identity of everyone working with and having access
to this record, and that
their integrity and honesty be thoroughly researched and clear.
Next, assure that
access to the records is also protected through the use of a
strong password that is
unique and used only for accessing these records. The make
certain that access to the
data is restricted to only those having a legitimate need.
Also be certain that the technology provides for authentication
by only the proper
authorities, and that an audit trail of access to the records is
created and maintained.
Clinical laboratory records are the subject of special regulations
under the Clinical
Laboratory Improvement Amendments (CLIA) wherever the
tests are performed
Even such things as notices to patients of their rights to speak
on their own behalf have

become the subject of regulations of information. Medicare has
such a requirement in
its form “An important Message from Medicare About Your
Rights”. This form notifies
patients of their right to question the timing of their release
from hospital care if it is felt
that they are being released too early to reduce billing.
Health care facilities are required by the U. S. Government to
retain patient records for
ten years, in most cases. Other governmental agencies and
payer or accreditation
organizations may have added requirements.
Upon expiration of the required retention period/s, there are
additional requirements
regarding the disposal/destruction of these records.
Coding of medical information preceded the introduction of
automation/computerization
in healthcare information processing, but the rather thorough
permeation of the
processing of healthcare information through computer
technology has increased the

speed and comprehensiveness of this activity. Coding simply is
the conversion of
words and phrases into unique sets of numbers so that the
processing of the
information may be more efficient and effective.
The first two major coding systems to become familiar with is
the International
Classification of Diseases (ICD) – Clinical Modification,
currently in its 9th edition,
therefore ICD – 9 – CM, and Current Procedural Terminology
(CPT). It is vital that only
valid, accurate data is passed to the agencies and third-party
payers who rely on this
information. To this end, the American Health Information
Management Association
(AHIMA) publishes Standards for Ethical Coding.
The most common areas of concern in accurate reporting
include the place of service
codes, duplicate billing, unbundling, phantom patients,
“incident to” services, services
not performed, and balance billing. Each of these areas are
more fully discussed in the

Textbook and should be studied in detail.
A new code, created on January 23, 2004, by the action of the
Secretary of the
Department of Health and Human Services, known as the
National Provider Identifier
(NPI) replaces all previous provider identifiers, including the
UPIN. This code is free for
the asking and is to be used for all claims forms used in billing
for physician and
outpatient services as well as for inpatient hospital claims.
Coders and billers are responsible under the law, not only the
Federal False Claims Act
but state and other counterparts to it, for filing claims that
contain false information if
they “know or should have known” that the information filed
was false. Ignorance of the
law is NO EXCUSE. Numerous examples of this are given in
the textbook in Chapter 7.
A number of other coding systems are in use and must be

recognized in carrying out
required compliance reporting. The Physician Quality Reporting
Initiative (PQRI) is a
voluntary reporting system that uses Category II codes. These
Category II codes are
separate from: Category I codes – or Regular CPT codes and
Category III Codes –
Emerging technology codes or HCPCS, Level II codes – for
ancillary services such as
durable medical equipment and medical supplies.
States vary as to the mandatory reporting requirements with
respect to domestic
violence, abuse and neglect, but most require physicians,
osteopaths, chiropractors,
nurses, health personnel engaged in the admission, examination
and care or treatment
of children, health professionals, and mental health
professionals, among others.
Likewise, in the case of communicable diseases, there is broad
legal and ethical
requirements placed on health care providers to report
contagious or communicable

symptoms that may lead to epidemics or pandemics.
MHCM 6320 Corporate Compliance and Legal Issues in
Healthcare
Chapter 6 Compliance Documentation
Chapter 7 Compliance Reporting
Week 5 Lecture Notes
It is important that the compliance program highlight this
requirement for adequate
documentation of all aspects of patient care delivery. The
documentation serves a
number of valuable purposes, besides the requirements of
compliance. Specifically, it
provides support for medical decision making, provides for
continuity of patient care,
supports patient and public safety, assists in the allocation of
resources, supports
research and education, and finally provides evidence of
compliance. Good

documentation also contributes to quality improvement
programs and supplies
necessary information to proper payment/reimbursement.
In order for documentation to serve all of these aspects of
patient care well, it must be
complete, accurate, timely and accessible. It should always be
signed or otherwise
confirmed.
A growing practice that presents considerable danger in any
documentation is the
practice of excessive abbreviations or use of mnemonics,
acronyms, symbols or other
shortcuts in word usage. This is a dangerous practice
throughout our culture,
aggravated by the use of texting and email as well as the
generally sloppy use of
language. No abbreviation should be used in a document
without first using the full
word or phrase to be represented by the shortened version.
Unfortunately, many
abbreviations have “twins” with totally different meanings, and
this can lead to

misunderstanding at the least and disaster at the greatest. This
problem has reached
the point that some organizations have published “Do Not Use”
lists of such
abbreviations.
The False Claims Act sets out specific elements for
documentation compliance.
According to the Act, patient records must be complete and
specific with regard to
medical necessity, certification of medical necessity, refunding
of overpayments,
contractual agreements with billing service companies, release
of information regarding
reimbursement, diagnostic X-Ray interpretation, certification of
compliance, dates of
service, and claims support.
The Federal Stark Law, which is reinforced or expanded by
many state laws, forbids a
referring physician from financial gain when referring a patient
to another physician –
usually a specialist, when the patient is a Medicare or Medicaid
beneficiary. This rule is

applied across a broad spectrum of referral situations and is not
restricted to only
physician to physician referrals, but includes referrals to
organizations or companies in
which the referring physician may hold an interest and therefore
benefit from the
revenue or any other benefit generated from the referral.
There is also federal legislation known as the Federal Anti-
Kickback Statute that makes
it a crime to exchange any type of benefit for a referral. This is
broader than the Stark
Law in that no involvement of Medicare or Medicaid is required
to be in violation.
There are certain required elements of documentation for
physicians in every patient
encounter. These elements must always be present: the date;
the patient identity; a
unique identifier for the patient; the identity of the provider; the
reason for the encounter;
details of all communications; details of any examination/s;
objective findings; complete

description of all services performed; follow-up orders;
provider’s signature.
Hospitals have an additional set of documentation requirements,
and these were
expanded in 2007 when the CMS mandated that hospitals report
those conditions
identified for each patient that were present at the time of
admission. There are also
specific requirements for documentation of physician’s notes in
the patient’s record.
Electronic Health Records (EHR) are finally becoming a reality.
Your instructor was
President of one of the three first companies in the United
States to develop total
hospital information systems (THIS), in the late 1960s-
specifically beginning in 1967. It
was an element of these early systems to produce an electronic
patient record as a by-
product of the use of these computer driven communication and
data collection systems
by capturing the medical information at the source and
processing it and recording it to
the finish. Unfortunately, the road has been very long and

frustrating and fraught with
not only technological difficulties but with patient care
deliverers resistance to change.
In 2004, President George W. Bush set a goal for
implementation of the electronic
health record by 2014. While that goal too has failed to be met,
progress has now been
great and the end result is definitely in sight.
As the dream becomes a reality, it is vital that the compliance
officer work with the
technology department to ensure that such a record be kept
secure. It is necessary to
assure the identity of everyone working with and having access
to this record, and that
their integrity and honesty be thoroughly researched and clear.
Next, assure that
access to the records is also protected through the use of a
strong password that is
unique and used only for accessing these records. The make
certain that access to the
data is restricted to only those having a legitimate need.
Also be certain that the technology provides for authentication
by only the proper

authorities, and that an audit trail of access to the records is
created and maintained.
Clinical laboratory records are the subject of special regulations
under the Clinical
Laboratory Improvement Amendments (CLIA) wherever the
tests are performed
Even such things as notices to patients of their rights to speak
on their own behalf have
become the subject of regulations of information. Medicare has
such a requirement in
its form “An important Message from Medicare About Your
Rights”. This form notifies
patients of their right to question the timing of their release
from hospital care if it is felt
that they are being released too early to reduce billing.
Health care facilities are required by the U. S. Government to
retain patient records for
ten years, in most cases. Other governmental agencies and
payer or accreditation

organizations may have added requirements.
Upon expiration of the required retention period/s, there are
additional requirements
regarding the disposal/destruction of these records.
Coding of medical information preceded the introduction of
automation/computerization
in healthcare information processing, but the rather thorough
permeation of the
processing of healthcare information through computer
technology has increased the
speed and comprehensiveness of this activity. Coding simply is
the conversion of
words and phrases into unique sets of numbers so that the
processing of the
information may be more efficient and effective.
The first two major coding systems to become familiar with is
the International
Classification of Diseases (ICD) – Clinical Modification,
currently in its 9th edition,
therefore ICD – 9 – CM, and Current Procedural Terminology
(CPT). It is vital that only

valid, accurate data is passed to the agencies and third-party
payers who rely on this
information. To this end, the American Health Information
Management Association
(AHIMA) publishes Standards for Ethical Coding.
The most common areas of concern in accurate reporting
include the place of service
codes, duplicate billing, unbundling, phantom patients,
“incident to” services, services
not performed, and balance billing. Each of these areas are
more fully discussed in the
Textbook and should be studied in detail.
A new code, created on January 23, 2004, by the action of the
Secretary of the
Department of Health and Human Services, known as the
National Provider Identifier
(NPI) replaces all previous provider identifiers, including the
UPIN. This code is free for
the asking and is to be used for all claims forms used in billing
for physician and
outpatient services as well as for inpatient hospital claims.

Coders and billers are responsible under the law, not only the
Federal False Claims Act
but state and other counterparts to it, for filing claims that
contain false information if
they “know or should have known” that the information filed
was false. Ignorance of the
law is NO EXCUSE. Numerous examples of this are given in
the textbook in Chapter 7.
A number of other coding systems are in use and must be
recognized in carrying out
required compliance reporting. The Physician Quality Reporting
Initiative (PQRI) is a
voluntary reporting system that uses Category II codes. These
Category II codes are
separate from: Category I codes – or Regular CPT codes and
Category III Codes –
Emerging technology codes or HCPCS, Level II codes – for
ancillary services such as
durable medical equipment and medical supplies.
States vary as to the mandatory reporting requirements with
respect to domestic

violence, abuse and neglect, but most require physicians,
osteopaths, chiropractors,
nurses, health personnel engaged in the admission, examination
and care or treatment
of children, health professionals, and mental health
professionals, among others.
Likewise, in the case of communicable diseases, there is broad
legal and ethical
requirements placed on health care providers to report
contagious or communicable
symptoms that may lead to epidemics or pandemics.

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