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Another reason to perform an internal audit according to RSM is to verify that the work flow in place is properly functioning and to see if any changes need to be made to make that process more efficient. The work flow that would be questioned is how demographics and insurance information is captured. How documentation is done and how revenue such as copays are collected (RSM Staff, 2017). The providers and clinical staff would then provide services and complete clinical documentation. Clinical documentation is essential in order to support the services that were performed on the patient. Clinical documentation takes place in the electronic medical records (EMR). Chestnut Behavioral Health Hospital has a team of chart auditors and their job is to perform audits on the documentation of all medical records. A medical records audit is a chart review which is used to identify what is being done correctly and what is in need of improvement (Nock, n.d.). Incorrect clinical documentation potentially has a big impact on and pay for performance incentives that are being offered. If clinical documentation is coded incorrectly then that leads to fraudulent claims, denied claims etc. The backend staff would then complete claims then submit. They would follow up on anyoutstanding balances, payment posting and denial management. The backend staff would be the Accounts Receivable department at Chestnut Behavioral Health Hospital. It is in this department
HCM 345 FINAL WHITE PAPER8where the claims are generated and submitted to insurance companies for reimbursement. The Accounts Receivable department at Chestnut Behavioral Health Hospital utilizes a third party billing agent called Trizetto. Trizetto is a billing provider solution company and assist in ensuring clean accurate claims are submitted to minimize denials. Trizetto allows Chestnut Behavioral Health Hospital to submit electronic claims to include professional and institutional claims, in a quick and efficient manner. This also allows for quicker reimbursement for services provided (Trizetto, n.d.). Failure to accurately submit claims and utilize a clearinghouse could also potentially impact the pay for performance incentives. According to the American College of Physicians Medicare and Medicaid offer Electronic Health Record (EHR) incentives. These incentives are also known as Meaningful Use incentives and they are essentially a financial “bonus” to healthcare professionals who utilize a certified Electronic Health Record (American College of Physicians, n.d.). Medicare and Medicaid offer this incentive because with the use of Electronic Health Record there is more efficient quality of care and increased patient safety (American College of Physicians, n.d.). If a provider meets the goals of pay for performance then they receive additional reimbursement. If they do not met those goals they lose out on reimbursement and this could potentially impact the financial stability of an organization.