Strategic Training on Policies, Procedures, and Regulation

Introduction 

Billing and coding in the healthcare sector are important to function that any health facility's management must take seriously. These two functions help healthcare workers translate a patient’s encounter into the languages that they can use for claims submission and reimbursement. However, it is important to note that although the two processes are related, they are different. Medical coding can be described as the process of extracting billable information from medical records and clinical documentation. Medical billing uses the mentioned codes to create insurance claims and bills for patients ( Doben, 2018 ). These two functions are important for streamlining processes and delivery of healthcare services to clients in a healthcare facility. It is also important to ensure that employees mandated with medical billing and coding have high integrity value. For example, an employee can collude with a client to make false claims based on mispresented facts to an insurance company. Also, a staff member decides not to forego billing procedures but later scheme with an employee of an insurance company to access patients’ insurance claims. This action plan focuses on assisting the management in understanding billing and coding frauds and training plans that will benefit concerned workers. 

Types of Fraud Associated with Medical Coding and Billing and Policies and Procedures That Can Be Used to Monitor Such Activities 

Upcoding 

There different types of medical coding and billing frauds that the management must be aware of and institute measures to prevent them from happening. Upcoding is the first billing fraud that is rampant in healthcare institutions. Upcoding happens when a worker submits codes for more serious medical diagnoses and procedures than they actually diagnosed or performed ( Bauder et al., 2017 ). A bill that has such fraud can be set to any payer, including a private insurer, patient, and government supported insurance schemes. The consequences of upcoding is an inflated medical cost for all involved payers because the government will distribute the cost among everyone. When a health institution upcodes a bill, the billers assign a code for more expensive procedures or services than the ones conducted. Upcoding can be mitigated by implementing a policy that requires each medical practitioner to document a comprehensive medical history. For example, such a policy should emphasize current procedure terminology documentation, which are codes, descriptions, and rules that describe each procedure performed by a doctor and other medical specialists. 

Phantom Billing 

Phantom billing is the second type of medical billing fraud. This fraud happens when a staff bills a payer for medical services or procedures that were never performed ( Palutturi et al., 2019 ). Phantom billing can occur when a healthcare staffer present claims for medically unnecessary procedures to clients who are either rich or never needed a certain procedure in the first place. Concerning this fraud, providers and their employees are not the only perpetrators, but they can collude with patients involved in medical insurance frauds in exchange for monetary kickbacks. For example, a physician can bill the government for hundreds of root canal procedures apparently performed on clients who had no teeth to treat. Since it is difficult to prevent or mitigate phantom billing, the hospital can enact and implement a program integrity education policy which should be open to all medical practitioner ( Sundean et al., 2019 ). The program should include principles of patient safety, malpractices and the risk they pose to the clients, and appropriate billing practices. Also, the policy should be able to address integrity issues arising from errors and inadvertent mistakes in both coding and billing. 

Service Unbundling 

The last common billing fraud is service unbundling. Unbundling occurs when a biller uses billing codes for more than one separate procedure when the procedures were performed together ( Palutturi et al., 2019 ). Consequently, a payer will end up reimbursing more money for bundled services. An example of service unbundling in a health facility is when surgery involves an incision. The incision will involve opening a patient, and later after the procedure, they will perform stitching to close up the wounds. The surgeon can decide to code opening and stitching as two separate procedures, which will force an insurance company to pay more money. Unbundling can be prevented through implementing similar policies to Medicare National Correct Coding Initiative (NCCI) edits. CCI edits prevent healthcare providers from fragmenting services when coding and billing services ( Myles et al., 2018 ). The NCCI policy provides for one table of edits for healthcare practitioners and a separate one for outpatient hospital payments. The goal of implementing a program such as NCCI is to prevent improper payments when medical procedures and services are presented with incorrect units of service. 

New Employee Orientation Program Outline 

New employees to this health facility must always be oriented on how to conduct billing and coding. An orientation program on different types of coding and billing errors is thus important because it will help new workers understand the impacts of such frauds on the institution, payers, and concerned employees. 

Learning Activities	Expected Outcomes	Undertaken by Who?	Leadership Style  Coaching style: The reason for this approach is that the persons mandated with orienting new employees want to help them be transparent, accountable, and careful when conducting coding and billing processes ( Cable & Graham, 2018 ).
Introducing the new employees to the coding and billing tools and other related templates that the organization uses	Each employee understands the billing and coding systems that the institution uses.	Human Resource Manager
Training the new employees on how to use the tools and their template	The new workers gain practical expertise on how to use the tools and processes.	IT Technical team and Human Resource Manager
Introducing the employees to the different types of coding and billing frauds	An employee understands the various types of coding and billing frauds and how they are perpetrated.	Human Resource Manager
Reviewing the available Policies on coding and billing	The employees will understand rules that govern billing and coding at the facility.	Human Resource Manager
Introducing the new employees to the legal and professional implication arising from coding and billing frauds	The workers will have an extensive understanding of the legal implications surrounding coding and billing frauds.	Company Legal Team and Human Resource Manager
Assessing the knowledge level of employees on coding and billing	Help the employees internalize concepts, principles, and dynamics of coding and billing, including the associated frauds.	Human Resource Manager

An Ongoing Training Program Outline 

Activities	Expected Outcomes	Person Responsible	Leadership Approach  Coaching style: The goal is to ensure that workers have a high level of integrity
Reviewing legal and professional surrounding coding and billing frauds	Cement the workers' knowledge on laws and professional guidelines on coding and billing and associated frauds	Legal and Human Resource teams
Reviewing the existing policies and regulations that govern coding and billing activities	Entrenching the employees’ knowledge about coding and billing irregulates and any emerging trends.	Human Resource Manager
Helping Employees identify, avoid and report coding and reporting errors	Reduce instances of human error while inculcating a culture of honesty within the facility	Human Resource Manager

Plan to Evaluate the Effectiveness of Training Program During Launch 

The process to Be Followed.	Description	Methods Used to Evaluate the Effectiveness of the Training  Kirkpatrick’s Four-level Training Evaluation Model: This method has four levels, which include  Assessing learners’ reaction to training  Measuring what was learned at the launch of the training programs  Assessing behaviors of learners after the introduction  Evaluating the expected impact of the program on the facilities success ( Reio et al., 2017 )
Identify the purpose of the training program.	The first step is to identify the reasons for the training programs. Understanding the learning objectives and the expected benefits to participants will be crucial.
Select the assessment method	Selecting an evaluation method will be the second step. Some of the tools that will be considered are interviews, focus groups, observations, and interviews.
Design tools to conduct the evaluation	The tool identified will then be designed with the intended use of the information being the major being the primary influencing factor.
Collect data on how the program is fairing	After designing the appropriate tool, data will be collected from the trainees and trainers.
Analyze and report the results	The last step will be to analyze data and report the findings. Only important elements will be considered for analysis.

Plan to Evaluate the Effectiveness of Training Program at Periodic Times Over the Next Two Years 

Levels	When Each Will be Tested	Reason for Testing	The assessment method to be adopted is Kirkpatrick's Four-level Training Evaluation Model.
Reaction	After 6 months	The focus will be to assess how learners continue to perceive the training program.
Learning	After 12 months since launch	During this phase, the evaluator will want to know what content the learners have accumulated after 12 months.
Behavior	After 18 months after launch	At 18 months, the assessment will center on whether the training has so far changed trainees' behaviors concerning the subject matter.
Impact	At the end of 2 years	The last phase will assess whether the trainee has positively impacted the trainee. The goal of a training program is to impart skills and knowledge on a certain discipline or subject.

Enterprise Data Warehouse 

The modern-day business environment is data-driven as decisions are increasingly being made based on data collected from different areas within and without a business. An enterprise such as a hospital can leverage an information asset such as an electronic health record (EHR) to collect data, which can give crucial pointers on the health dynamics of the facility's patients. As such, future deliberation on the best approach to manage patients will be data-driven. An enterprise data warehouse (EDW) is a huge data reservoir that centralizes an organization's information from multiple sources and avails it for analytics and use across the entire business. For example, a health facility can have EHR, billing systems, telemedicine systems, clinical applications, and personal health records, among others. Data from these systems can be centralized in an EDW, which makes it readily available for analysis and thus facilitating seamless decision making. The second advantage of an EDWs is that they provide context and demonstrate the associations between data from different sources ( McGlothlin et al., 2017 ). For instance, such a system will show the relationships between data from an EHR and clinical applications such as laboratory app. With such relationships clear, it will be possible to understand what the information means and where it can be applied. 

Strategic Objective: Improve healthcare quality, safety, cost, and value. 

An EDW can be used to achieve this strategic objective by analyzing certain data stored in it. Today, the focus is to implement policies and models that promote patient-centered care, a goal that is defined by patient safety, quality care, and reduced cost of care. In order to realize the stated objective, the organization should analyze data stored in the EDW from systems such as EHR, clinical applications, payment division, feedback systems, master patient index, patient portals, and health information exchange (HIE). Analyzing these data sets will help the management understand disease profiles, service delivery weaknesses and strengths, patients' preferences, and trends in the health sector. From such analyses, the management will be able to lay down policies and mechanisms to improve service delivery and establish a culture of patient centered care. 

Electronic Health Record : Data from EHRs, when analyzed through an EDW's analytic engine, can help identify potential safety problems when they happen, thus assisting providers in avoiding more serious problems in the future. For example, when well utilized, the EDW will show why certain medications or procedures are associated with increased mortality rates. Therefore, the management and medical staff will plan for drugs that are safe, which will lay a foundation for better treatment outcomes. 

Billing Systems : As mentioned, fraud is one of the factors that result in inflated costs in the healthcare sector. Data from billing systems can be analyzed through an EDW’s analytic engine to identify how different patients with similar health issues were charged. For example, data on patients who underwent chemotherapy sessions in the hospital should show a similar payment pattern in a given period. Through such analyses, fraudulent activities will be identified hence helping reduce the cost of healthcare. 

References 

Bauder, R., Khoshgoftaar, T. M., & Seliya, N. (2017). A survey on the state of healthcare upcoding fraud analysis and detection.  Health Services and Outcomes Research Methodology ,  17 (1), 31-55. 

Cable, S., & Graham, E. (2018). “Leading Better Care”: An evaluation of an accelerated coaching intervention for clinical nursing leadership development.  Journal of nursing management ,  26 (5), 605-612. 

Doben, A. (2018). Billing and Coding. In  Rib Fracture Management  (pp. 165-173). Springer, Cham. 

McGlothlin, J. P., Madugula, A., & Stojic, I. (2017, February). The Virtual Enterprise Data Warehouse for Healthcare. In  HEALTHINF  (pp. 469-476). 

Myles, J. L., Synovec, M., Klemp, T., & Black-Schaffer, W. S. (2018). Current CPT Coding and Payment Policy Implications for Immunohistology Services.  Advances in anatomic pathology ,  25 (6), 430-433. 

Palutturi, S., Makkurade, S. R., Ahri, R. A., & Putri, A. S. E. (2019). Potential for fraud of health service claims to BPJS health at Tenriawaru Public Hospital, Bone Regency, Indonesia.  International Journal of Innovation, Creativity, and Change ,  8 (5), 70-90. 

Reio, T. G., Rocco, T. S., Smith, D. H., & Chang, E. (2017). A critique of Kirkpatrick's evaluation model.  New Horizons in Adult Education and Human Resource Development ,  29 (2), 35-53. 

Sundean, L. J., White, K. R., Thompson, L. S., & Prybil, L. D. (2019). Governance education for nurses: Preparing nurses for the future.  Journal of Professional Nursing ,  35 (5), 346-352.