“The documentation, history, and trends that arise from a gap analysis process can be especially valuable for new managers” (Healthcare Financial Management Association, 2008, para. 13). As an employee of a Medicare Administrative Contractor (MAC) for the Centers for Medicare & Medicaid Services (CMS), the author will be performing a gap analysis to gain insight into claims administration. The purpose of this paper is to describe the process of interest and outline the plan for conducting a gap analysis.
Determination of Medical Necessity
Medicare benefits are issued to eligible beneficiaries through a number of Medicare Administrative Contractors (MAC). Similar to the meaningful use ...view middle of the document...
While the current medical review practices at Well Health meet the CMS mandates, there are concerns regarding adherence to the claims adjudication timeframe set forth by another regulating body, URAC, formerly known as the Utilization Review Accreditation Commission (T. Miller, personal communication, December 31, 2013). Therefore, the goals of this gap analysis are two-fold; 1) to determine where gaps exists in the medical necessity review process at Well Health, and 2) to identify specific areas that would benefit from intervention. In addition, this author hopes to gain a better understanding of the claims administration and overall healthcare reimbursement methods currently used nationwide.
Data Collection Plan
The first phase in a gap analysis plan involves collecting data relevant to the process of interest; in this case, the medical necessity review process at Well Health. Amaral and Faria (2010) suggest the following steps:
• Meet with department leaders to gather initial information about the process
• Observe the process being carried out by many different nurse reviewers
• Validate finding by interviewing a variety of process stakeholders
Copious notes will be taken during each step, along with drawing a rough draft of the related flow diagram. The tentative flow chart will be shared with interviewees during the final stage of the data collection process.
In order to avoid disturbing the medical necessity review workflow and potentially disrupting this production environment, the observer will be paired with experienced nurses. Furthermore, the observer will limit the number of questions asked to the reviewer as clarification can be achieved during the closing interviews. Untoward bias will be prevented by selecting a broad range of stakeholders to question; this will ensure that different points of view are included in the findings (Amaral & Faria, 2010).
Final Preparation for the Gap Analysis
Compiling all of the relevant data into a simplified format will enable the author to identify weak points in the review process, and determine areas for intervention. Two tools...