Medical Eligibility Bill and the Improvement of Audit Procedures - Term Paper Example

?Memorandum CC: 6/3 Re: Thesis ment: Medical eligibility bill and the improvement of audit procedures. Executive Summary Medical eligibility bill is the procedural attempt of amending the existing legislation which will improve the treatment of patient or applicant or beneficiary meanwhile in the presumptive eligibility period. Presumptive eligibility is the emergency period of immediate medical treatment before the formal application procedure. In addition to this the audit improvement act will provide improvement in the internally generated audit evident documents and the other audit procedures. The audit procedures are the major compliance methods in verifying the records. The statute provides the guidelines for these procedures which have been established with the passage of time through the legislation process. The over and underpayments requires documentation while auditing the revenant categories and these sections are one of the high risks because this involves high amounts and the material transactions. The individual transactions may not be material but the sum of these transactions eventually become material for the sake of the substance of the transactions. The audit evidences are gathered by the Recovery auditors who act on the behalf of the government and audits the employees of the government in the medical departments of the hospitals. These evidences are based on the factual information containing the information of the patient and the hospital and the relevant medical staff involved in the transactions. The auditors use these evidences to support their opinion on the information for which they are hired for. The reported information is issued to the government and the stakeholders and is the source of the certified procedures. During this process the medical staff and the auditors have to follow the procedures given by the statute and the regulatory authorities and sometimes these procedures overburden the staff which prevents the medical staff to be stuck in the compliance procedure. A formation of the number of required documentation can provide the solid basis for the auditors and will improve the clarity of operations of both the medical units and the audit reports. Section: 1 Problem Statement: Should the presumptive eligibility be streamlined and should the staff be over burdened with the compliance procedures? Defining the Problem Evidences for the post payments and the prepayments in the form of documents are requested by the auditors and these will be subject to a certain limit. There is certain disambiguation for the quantitative amount of the required documents. If remained unattended, it will increase the administrative burden and cost; whereas it will improve clarity for the audit procedures as well it will harmonize all the hospitals into a proper format for the audit procedures. The audit improvement act would reinstate and make statutory a hard cap on additional documents requests (Grave. House. Gov. 2012). The presumptive eligibility period of a patient is a period which requires immediate medical treatment. The low level income applicant or patient is identified for the relevant department or institute for either state subsidy of the federal subsidy. Defining the Policy Problem The functioning of the organization is documented for their financial internal and external information; relevant to both quantitative and qualitative aspects of the operations. The compliance structure relevant to the required internal documents is the major source of satisfying the audit evidences and these evidences provides the factual basis for the true and fair nature of disclosed and published institutional information. Key Stakeholders The ministry of health and the subsequent federal and state Medicare institutions are the immediate stakeholders in addition to this it is also providing the benefit to the low-income patients. The low-level income patients are the receivers of this centrally streamlined procedural reform. For the audit improvement act, the internal audit department, the patients, the government, the tax authorities, the pharmaceutical industries and employees are the stakeholders at large. The Office of Inspector General was not able to recover $332 million because they were not able to recover more than three years and this was reflected in 154 audit reports. (McKnight’s 2013). The government has a keen interest as it provides the budget for health and the auditors are the agents of the government, whereas the medical staff is providing the facility which is being audited and the issue of this topic. Emergence of the issue Trends The general procedures required from the regulatory authorities will be improved, it will reduce the administrative burdens as well it will make smooth the prepayments and the post payments schedules and their proper cutoffs represented in the unqualified published information, which is extracted from the audit procedures. The recovery auditor may go for more than 45 days back to check the records and for the hospitals crossing the threshold of $100,000,000 will be providing the 600 documents to be audited for the given period. In the context of the medical eligibility bill, the existing law requires the written request with the options stated and the physical presence of applicant during the approval process. In addition to this the gender, ethnic region, race and age are also being authorized as being of voluntary nature in the form filling process. Cost The identified subsidy from the state or federal health institution shall be liable for the applicant. The options, as above mentioned, will realize the patient choice, and in the absence of written request for certain options, the adequate procedures shall be applied for the applicants’ medical plan. The audit improvement act will reduce the cost of document maintenance. This reformation will result in reduction of cost as well it will improve the efficiency of audit as it will target the material transactions only. It will save the time and will eliminate the procedures for the document evidencing. Quality A framework for the patient shall be improved and he/she will be told for the managed plan or fee for service options available. The quality of audit will be improved as it will put light on the material transactions and will consider the information that is relevant and true, reflected from the internal and external evidences. The objective and unbiased judgment will improve the quality and will reduce the risk of misstatement. The doctors and other staff should not be burdened with increasing audit requests (The Hill 2013) Section: 2 Need for govt. intervention There is a need for government intervention to get out from the loopholes of under and over documentation and the medical eligibility bill. The prepayments are the payments in advance relevant to any specific month and the post payments are the payments after the provided service and hospitality. The government needs to intervene in this case as a regulatory authority and should make their proposed legislation according to the need of Medicare institutions. There are two ways of compliance with the generally accepted accounting practices, the first one is making the existing laws according to the GAAP and the second is accepting the GAAP and making it suitable according to the local requirements. The federal and the local government is the major stakeholder in this case as it provides the funding to the hospitals. These funding are provided in the form of prepayments and the post payments and to the low-income or the deserving applicants, and to prevent and detect frauds and errors the government should check them. The individual who are holding the associate degree and have good professional skills can perform the role as audit recovery officer. As these recovery auditors are the representative of the government, they act on the behalf of the government and so they are the agent of the business. These government agents needs to ensure the proper utilization of the funds and if the funds are unused, they must be given back Legislation Existing Policy The existing policy on the given issue is the 400 requests allowable per 45 days. A different opinion regarding the increment and decrement are found on this issue but for the increment, it is said to be increasing the burden on the hospital staffs, so limiting the audit document request will be doable for the staff and they will be able to function properly, rather than complying with the audit procedures. The factor behind the issue of this bill is to make procedures on the eligibility procedures for a patient, to repudiate the clause of physical presence while the processing of the application, and providing the detail information. The other causes for the introduction of this bill was to eliminate the procedure of the health care department required for the Medical Managed Care Plan MCP and the inclusion of demographic type questions, which are of the optional nature, for the applicant. In contrast to this the medical eligibility bill this bill will allow a federal hospital to cover the expense of the qualified person with medical aid. Overview of legislation process The existing law let the Health Care Department to enter into agreement with the patients which is to be repealed by this law. The passing of this bill will give the more eligible person the facility of funded medical treatment in general terms and this law is expected to be passed through legislation and is of urgent nature.A legislation in the legislative process needs to be passed from the legislation process, it has to pass six steps from the beginning to end at all. The first two steps are introduction and Referring to the committee. At these steps the discussions and debates are held over the provided issues. After meeting the required numbers by constitution, the bill is further preceded and passed. These steps are the most vital steps in any legislation and needs lobbying and political and social influence. The last steps in this process are just the formal steps and at this stage the legislation is passed by senate and signed by the president. Usually, majority of the legislations pass these last steps quite easily Audit Evidences and procedures Documents gathered as the evidence against the relevant treasury functions are the audit procedures implied by the state and the statute. These are the documents which include the receipts signed and filed by the patient and the relevant officer at the hospital which may be a doctor, nurse or other staff. These files shows the expenses as well as the necessary information required around these expenses Medicare contractors will be assessed for identifying payments resulting from; incorrect payment amounts, non-covered services, incorrectly coded claims, duplicate claims (Nicholson Eastin). The legislation will give benefit to the emergency patients and the State health departments funds are subject to use for providing the health services. The medical eligibility bill and the audit procedures will provide structure of Medical service more clarity. The records can be verified by firstly directly contacting the patient, and the patient can be selected by the statistical sampling. The statistical sampling makes it possible to check the random records as the al records cannot be checked where the volume of transactions is too high. Section: 3 Identify stakeholders including industry, consumer groups, key legislators and others who have interest and influenced by the decision. The main stakeholders which have the strong position are the audit contractors and the hospital itself. The general public has interest but will not be directly affected by this decision as these two will be affected. Tax Authorities Tax authorities are the other stakeholders who have interest in this information because the information is certified for their authenticity by the auditors which are regulated by the auditing authorities at the governmental level. The tax authorities and the other federal agencies also use the information gathered because the information is relevant and is ensured for the rules of either correctly working autonomous organization or the factual information of their integrity and independence. Medical Staff The employees and the working bodies are also the main stakeholders and these are the employees who maintain these records, so checking the integrity of the employees through the audit procedures is ensuring the reduction of the risk. Audit is based on reflexology and the consequences are judged. The consequences are the predictors of the causes and these causes are worked back through the evidences and the general environment of the integrity is also assured for the autonomous working of the organization. This is called the evaluation of the system while the performance of audit. The checks system are incorporated in the organization for the relevant procedures which is the prepayment and the post payments, so observing that appropriate checks have been placed for any aspect of the organization’s transaction will alarm any misstatement and will highlight any discrepancy, as well it will also comment on the consistency of following the procedures. These comments are noted by the auditors in their report and are forwarded to the shareholders provided any extraordinary events. Government Government is very strong stakeholder and has key affects in this case. It is the duty if government to ensure the appropriate practices in any industry so this legislation, a part of which is under consideration, is prospected to be influenced by the government. This influence will improve the quality of audits of the Medicare hospitals and the payments section will be consolidated for their integrity into the audit reports. Section: 4 Projection of The errors Auditing is a very different trade and is usually related to the rules and regulations to the autonomous regulatory bodies. The regulators assure the compliance with the auditing standards and these standards vary from place to place according to the nature of the economy and the style in which financial information is presented. The application process requires the consent of the patient for the chosen medical plan. The applicant may subject to the state weaver ship or fee for the service and the procedures are there to serve this aim but it requires certain streamlining to resolve the overwhelming issues of documentation and the medical eligibility criteria. Prepayments and post payments are verified in audit using the evidences such as the receipt, the internal system of the hospital, the honesty level of the management and the external evidence available from the patients at the hospital. This bill will address critical problems in operations related to the Recovery Audit program(HCPRO 26 March 2013) The external evidences are specially appreciated because of the independence in these and they are not supposed to be affected by any manipulation or more accurately and misstatement. The reason is the absence of any self interest in any transaction and these are usually obtained from the clients of any organizations. The documentations are filed with the reports on the performance of the hospitals and provide the basis for making the report on the financial information. These audit reports state that Analytical Statistical interpretations The analytical statistical interpretations has been provided (CMS.Gov) Projected improper Payment (in Billions $) DRG Length of stay Error rate Projected improper payments (in billions $) Insufficient Documentation No Documentation Medically Unnecessary Overall incorrect coding Overpayment due to incorrect billing Underpayment due to Incorrect coding 1 Graves. House. Gov 2013. Reps. Graves and Schiff Introduce Bipartisan Legislation to improve Medicare Audit system. Web 19 May 2013 < http://graves.house.gov/latest-news/reps-graves-and-schiff-introduce-bipartisan-legislation-to-improve-medicare-audit-system/ > HCPRO 26 march 2013. Medicare Audit Improvements Act reintroduced, AHIMA shows support. Web. 19 May 2013 < http://www.hcpro.com/CCP-290501-5091/Medicare-Audit-Improvement-Act-reintroduced-AHIMA-shows-support.html > McKnight. Statute of Limitation for mideicare overpayment recovery extended two years, 8 January 2012. Web. 19 May 2013 < http://www.mcknights.com/statute-of-limitations-for-medicare-overpayment-recovery-extended-two-years/article/275164/ > NIcholsoneastin. Medicare and Medicaid Audits and Appeals. Web. 19 May 2013 http://www.nicholsoneastin.com/practice-areas/health-care-law/medicare-and-medicaid-audits-and-appeals/ AB-50 Medical eligibility bill Read More