A medical clinic discovers that its software had been discarding modifiers entered during preparation of data for submission to one third-party payers reimbursement. For a period several?
A medical clinic discovers that its software had been discarding modifiers entered during the preparation of data for submission to one third-party payer's reimbursement. For a period of several months, the clinic missed out on appropriate payments as a result. The clinic director has asked you to calculate the total amount of lost reimbursement for that period and to determine what steps to take to ensure this does not happen again.
Step 1: Determine the total amount of lost reimbursement.
To determine the total amount of lost reimbursement, you need to review a sample of the claims that were submitted without the appropriate modifiers and calculate the difference between the amount that was paid and the amount that would have been paid if the modifiers had been included. Based on your review of the sample claims, you estimate that the clinic lost an average of $100 per claim due to the software error.
Step 2: Calculate the total number of affected claims.
Next, you need to determine the total number of claims that were affected by the software error. The clinic's IT department can provide you with a list of all the claims that were submitted during the period when the software error was active. By reviewing this list, you estimate that a total of 1,000 claims were affected by the error.
Step 3: Multiply the average loss per claim by the total number of affected claims to calculate the total amount of lost reimbursement.
Based on your estimates, the clinic lost a total of $100 per claim * 1,000 claims = $100,000 in reimbursement due to the software error.
Step 4: Determine the steps to take to ensure this does not happen again.
To ensure that this does not happen again, the clinic should take the following steps:
1. Update the software. The clinic should work with its software vendor to obtain the latest version of the software, which should include the fix for the modifier discard error.
2. Retrain staff. The clinic should retrain its staff on the proper use of the software, including how to enter modifiers correctly.
3. Implement a claims review process. The clinic should implement a claims review process to ensure that all claims are being submitted correctly before they are sent to the payer.
By taking these steps, the clinic can help ensure that it does not miss out on any future reimbursement payments due to software errors.