Pharmacology Financial Implications of Wrong Medication
SCENARIO
You are a clinical documentation improvement coordinator. You are reviewing the record for a discharged patient that you received for review due to a rejected claim. You notice there is documentation of medications administered to the patient in the progress note indicating blinatumomab infusion. However, the medication reconciliation section in the EHR states blood transfusion. As you continue to look through the patient record, you confirm that blinatumomab is the correct infusion and note that the correct infusion is billable for $6,900 more than the blood transfusion. You look through your database and find that this same error happened six other times this year. Since there is a pattern for blood transfusion being coded and billed for blinatumomab infusion, you pull up the medication reconciliation section of the EHR and discover that there is a drop-down box and the choices are alphabetized. Blinatumomab infusion comes right before blood transfusion. You have brought this issue to the attention of your supervisor. Your supervisor has asked you to provide a report for senior management regarding the error, recommend a corrective action plan, and discuss further legal issues and responsibilities for HIM professionals.
REQUIREMENTS
A. Analyze the scenario, and write a report for senior management discussing the financial, quality-of-care, and legal issues related to incorrect medication entry and incorrect billing by doing the following:
1. Discuss the financial impact on the hospital when errors like the one described in the scenario occur.
2. Discuss the quality-of-care and legal issues related to the data-entry error described in the scenario.
3. Recommend a corrective action plan to ensure the error described in the scenario does not recur.
B. Explain the legal requirements for pharmaceutical reimbursement by doing the following:
1. Discuss the application of the National Drug Code (NDC) to the coding and billing function in the scenario.
2. Explain the steps an HIM professional should take to report suspected fraud and abuse in collected data.
3. Explain the importance of a pharmacy revenue cycle internal audit based on the scenario.
4. Discuss three important points that should be considered when conducting a pharmacy revenue cycle internal audit.
a. Justify why these points are important to consider.
C. Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.
D. Demonstrate professional communication in the content and presentation of your submission.
PHARMACOLOGY FINANCIAL IMPLICATIONS OF WRONG MEDICATION
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Financial impact
The scenario described highlights the importance of accurate coding and billing practices for the hospital. When errors occur, as in the case of the blood transfusion being billed as a blinatumomab infusion, the hospital suffers financially. This particular error resulted in an underpayment of $6,900 each time it occurred, and the cumulative impact of six such errors led to a loss of $41,400. Additionally, the hospital must allocate resources to correct the errors and resubmit claims, which also comes at a cost. Beyond the direct financial implications, billing errors can also harm the hospital's reputation, which may discourage patients from seeking care there in the future. It is crucial, therefore, that the hospital take measures to ensure accurate coding and billing procedures.
Quality-of-care and legal issues
In this case, the implications of the data-entry error cannot be understated. The process of medication reconciliation is critical for patient safety, and inaccurate documentation can have far-reaching consequences. When healthcare providers are not working from the same, accurate information, they may make decisions that compromise the patient’s quality of care. Specifically, in this scenario, a physician could inadvertently delay or alter treatment based on the incorrect information that the patient received a blood transfusion rather than a blinatumomab infusion. Documentation must be accurate and up-to-date to prevent such errors from occurring.
The potential legal ramifications of the data-entry error are substantial. Intentionally billing incorrectly may be classified as fraud, leading to fines, penalties, or criminal prosecution. Additionally, inadvertent errors can result in improper payments that need to be refunded. There is also the possibility of malpractice or negligence lawsuits if inaccurate medication documentation results in patient harm. As HIM professionals, we must prioritize the accuracy and integrity of health information to meet our responsibilities and avoid these issues.
Corrective action plan recommendation
A multi-pronged approach should be taken to correct the error described in the scenario. First, a review of the medication reconciliation section of the EHR should be conducted to determine if any changes to the drop-down menu or user interface could be made to prevent this error from happening again. For example, suppose the drop-down menu is alphabetized. In that case, adding a visual separator between blinatumomab infusion and blood transfusion may help to distinguish the two options and prevent confusion. Next, the team should review the records of patients who received blinatumomab infusion to identify any other instances where the incorrect medication was billed. This will help to quantify the extent of the problem and ensure that any necessary adjustments are made to patient bills. The team should also review billing and coding procedures to determine if there are other areas where similar errors could occur. If necessary, changes to policies and procedures should be made to reduce the risk of future errors. Finally, staff training should be conducted to reinforce the importance of accurate medication entry and billing. This training should highlight the potential consequences of errors, such as lost revenue, incorrect patient care, and possible legal issues. Staff should be provided with detailed instructions on properly using the EHR, and additional supervision or monitoring may be necessary to ensure compliance.
To address the error described in the scenario, a root cause analysis should be conducted to identify the factors that led to the error in the first place. This analysis will help the team understand how the error occurred and what changes need to be made to prevent it from happening again. The organization should also implement an audit and monitoring process to review the accuracy of medication entries and billing regularly. This will help detect errors early and prevent them from recurring problems. Lastly, a communication plan should be developed to ensure that all stakeholders know the error, the corrective actions are taken, and the importance of accurate medication entry and billing. This communication plan should include educational materials, training sessions, and regular updates on the status of the corrective action plan...