Ukuqonda Ububanzi bama-akhawunti abuyiselwe
Umgomo jikelele wokuphathwa kwama-akhawunti okumele uzuze ukufeza isikhathi esincane esifanele sokuqoqwa. Ama-receivables ama-akhawunti, eyaziwa nangokuthi ama-akhawunti wegulane, abhekisela kwimali engenayo eyakhiwe kodwa engakaqoqiwe. Ukuqinisekisa ukugeleza kwemali kukwanele ukuphathwa okusebenzayo, ihhovisi lezokwelapha linomthwalo wokwandisa amathuba okuthola imali.
Ukuphathwa kwe-akhawunti eyamukelekayo (AR) kuhilela cishe zonke izindawo zehhovisi lezokwelapha.
Ukuphathwa okuphumelelayo kwama-akhawunti okumele kutholakale kudinga ukuqonda ngokugcwele ukuthi indawo ngayinye noma umnyango uhlobene kanjani futhi uthonya umjikelezo wemali kanye nesikhathi sokuqoqa i-AR. Ake sihlole izindawo eziyisikhombisa eziyinhloko.
1. Imiqondo yezomthetho
Imiqondo esemthethweni ihlanganisa ukuqonda nokulandela imithetho kahulumeni kanye nesifundazwe. Indawo ehlale iwukukhathazeka kakhulu ukukhwabanisa nokuhlukunyezwa, ikakhulukazi mayelana neMedare, iMedicaid, nezinye izinhlelo ezixhaswe ngezimali.
Ukukhwabanisa kubhekisela ekumangalisweni ngamabomu ngokuzikhandla nangokwaziyo kwezokwelapha emzamweni wokuphinga noma yiluphi uhlelo oluxhaswe ngemali lwemali. Izinhlobo ezivame kakhulu zokukhwabanisa nokuhlukunyezwa zihlanganisa ukukhokhiswa kwemishini engakaze inikezwe, ukukhokhiswa kwezinsizakalo ezingakaze zenziwe, amacala okukhwabanisa ukuze uthole isilinganiso esiphezulu sokubuyiselwa, nokukhishwa kwamacala.
Ihhovisi le-Inspector General (OIG) lenzelwe futhi lanikeza izaziso ezikhethekile zokukhwabanisa emphakathini wokuhlinzeka ngempilo.
Lezi zixwayiso zazihloswe ukusabalalisa izindlela zikazwelonke zokukhwabanisa emphakathini jikelele. Futhi kuyindlela yokunikeza ukuqonda nokuqaphela imikhuba yokukhwabanisa ngaphakathi kwemboni kanye nokwephula ikheli okuqondene noMthetho we-Medicare ne-Medicaid Anti-Kickback Law.
2. Inkontileka Yokuxoxisana
Ukuxoxisana kwe-Contract kuhilela ukuthuthukisa ubuhlobo bezezimali nezinhlangano zokunakekelwa eziphethwe.
Izinhlangano zokunakekelwa eziphethwe zimele amaphesenti angama-50 emali engenayo yamahhovisi amaningi ezokwelapha.
Ukuxoxisana ngezivumelwano zokunakekelwa okuphethwe ukudinga kudinga ulwazi olunzulu lwenqubo yokuthola inkontileka. Lokhu kuhlanganisa amanani okubuyiselwa, izinsuku eziphumelelayo neziqedile, imihlahlandlela yokufaka isicelo, izinkokhelo zokukhokha kanye nezinye izinhlinzeko zezinkontileka.
Isu ngalinye lesikhungo sezokwethula inkontileka yehhovisi lezezimboni lihlukile futhi lizosekelwe ezintweni ezihlukahlukene, kodwa le mibono eyisisekelo kufanele igcinwe engqondweni:
- Yazi imakethe: Uyazi ukuthi yimaphi amaphesenti emakethe yakho ayenayo i-Medicare, Medicaid, Cigna, Blue Cross Blue Shield, Aetna, United HealthCare noma engaqinisekisiwe? Ucwaningo lwemakethe luhlinzeka ngolwazi olubalulekile oludingekayo kuzo zonke izingxoxiswano zezinkontileka.
- Yiba nomqondo onengqondo: Ukuqonda imvelo yokunakekelwa ephethwe kuhlanganise nezindlela ezehlukene zokukhokha kuzokunikeza isisekelo solwazi oludingekayo ukuthatha indlela engokoqobo ekuxoxweni.
- Ukuqasha umxhumanisi: Izinhlangano eziningi zithembele ekuboneni izinsizakalo zokuhlinzeka ngezinhlinzeko eziphathekayo zokuhlinzeka ngokuxoxisana ngenxa yenkimbinkimbi yezinkontileka kanye nezici zomthetho ezihilelekile.
Iseluleko sezomthetho kufanele sixoxwe kuzo zonke izinkinga zezinkontileka lapho kunezinkinga eziningi futhi ezihlukahlukene ezinhlanganweni noma uma izinkinga zenkampani zingekho ngaphezu kobuchwepheshe bobuholi behhovisi lezokwelapha.
3. Ukuthobela
Ukuthuthukisa uhlelo lokuhambisana nokubandakanya kuhlanganisa ukusungula incwadi ebhaliwe ichaza inqubomgomo yokuhambisana ne-Medical Office Code of Conduct. Iningi lemithetho yezokwelapha ukuhambisana nemigomo ifaka phakathi kokubili imibono yokuziphatha nokusemthethweni. I-OIG (i-Office of Inspector General) inikeza lezi zici eziyisikhombisa ezihlinzeka ngesisekelo esiqinile sohlelo lokuthobela ihhovisi lezokwelapha.
- Ukuqhuba ukuqapha kwangaphakathi nokuhlola;
- Ukusebenzisa amazinga okuhambisana nokulandela;
- Ukuqoka iphoyisa lokuthobela noma uthintana naye;
- Ukuqhuba ukuqeqeshwa kanye nemfundo efanele;
- Ukuphendula ngokufanele ukuthola amacala nokuthuthukisa isinyathelo sokulungisa;
- Ukuthuthukisa imigqa yokuxhumana; futhi
- Ukuphoqelela izindinganiso zokuqondiswa kwezigwegwe ngokusebenzisa iziqondiso ezishicilelwe kahle.
4. Amalungelo abaguli
Ihhovisi lezokuPhathwa kwabasebenzi base-United States likhomba izinhloso ezintathu ezinkulu zokuthuthukiswa kanye nokusetshenziswa kwamalungelo abagulayo.
- Okokuqala, ukuqinisa ukuzethemba kwabathengi ngokuqinisekisa uhlelo lokunakekelwa kwezempilo lufanele futhi luphendule izidingo zabathengi, lunikezela abathengi izindlela ezifanele futhi eziphumelelayo zokubhekana nokukhathazeka kwabo, futhi kukhuthaza abathengi ukuba bahlanganyele ekuthuthukiseni nasekuqinisekiseni impilo yabo.
- Okwesibili, ukuqinisekisa ukuthi ukubaluleka kobudlelwane obuqinile phakathi kweziguli kanye nabaqeqeshi babo bezempilo.
- Okwesithathu, ukuqinisekisa ukuthi iqhaza elibalulekile labathengi lidlala ekulondolozeni impilo yabo ngokusungula kokubili amalungelo kanye nemithwalo yemfanelo kubo bonke abahlanganyeli ekuthuthukiseni isimo sezempilo.
Kunezindawo eziyisishiyagalombili eziyinhloko ezihlobene namalungelo esiguli ngaphakathi kwehhovisi lezokwelapha.
- Ukwaziswa kwesineke: iziguli zinelungelo lokuthola ulwazi olunembile nokuqondakalayo mayelana nesimiso sabo sezempilo, ochwepheshe bezempilo kanye nezindawo zokunakekelwa kwezempilo.
- Ukukhetha abahlinzeki: iziguli zinelungelo lokukhetha abahlinzeki bezempilo uma zidinga.
- Ukufinyelela ezinsizakalweni eziphuthumayo : iziguli zinelungelo lokuphathwa okwelashwa oluphuthumayo kungakhathaliseki ukuthi likwazi ukukhokha.
- Imvume enolwazi: iziguli kufanele zivume kuphela ukwelashwa uma zinezokwanele mayelana nokuxilongwa kwazo nazo zonke izinketho zokwelashwa ezitholakalayo ngokwemibandela abangaziqonda.
- Inhlonipho kanye nokungabandlululo: iziguli zinelungelo lokucabangela, ukunakekelwa okunenhlonipho kuzo zonke izikhungo zokunakekelwa kwezempilo futhi zingabandlululwa ekuhlinzekeni kwezinsizakalo.
- Ukuyimfihlo: iziguli zinelungelo lokuxhumana okuyimfihlo futhi zibe nemfihlo yolwazi lwabo olubonakalayo oluvikelwe ngabanye.
- Izikhalazo nezikhalazo: iziguli zinelungelo lokuxazulula okulungile nokusebenzayo kwanoma yisiphi isikhalazo esenziwa ehhovisi lezokwelapha.
- Imithwalo yemfanelo yeziguli: iziguli zinemithwalo yemithwalo yemfanelo ehhovisi lezokwelapha kubandakanya iqhaza elibambisene ohlelweni lwabo lwezokwelapha, ukuxazululwa ngesikhathi esifanele kwesibopho sabo sezimali nokusebenzisana ngenhlonipho nabo bonke abasebenzi.
5. Ukufinyelela kwesineke
Impumelelo yehhovisi lakho lezokwelapha lixhomeke kakhulu ekusebenzeni kahle kweziguli zokufinyelela (noma abasebenzi bokugcina). Umjikelezo we-akhawunti yesiguli uvela ekungeneni kokuqala kolwazi lwesiguli sabantu. Ukwakhiwa kwethimba lokufinyelela kwegciwane le-dynamite kuyisinyathelo esibalulekile ekuthuthukiseni imizamo yokukhokha kanye nokuqoqa kanye nokwandisa ukusebenza komjikelezo wemali.
Izizathu ezijwayelekile zokuthi kungani amaqembu amaningi ezinsizakalo zokufinyelela ezigulini anesilinganiso esincane sokusebenza ukungabikho kwemithombo efanele, ukuqeqeshwa okunganele, kanye namazinga angasebenzi okwanele. Ngenhlanhla, lezi zixazululo ngokushesha futhi ngaphandle kwezindleko ezinkulu.
6. Ukukhokhiswa kuthathwa
Ukubaluleka kwecala lokukhishwa kufanele kuboniswe kuyo yonke iminyango. Abasebenzi bemitholampilo kumele baqaphele umthwalo wabo wemali kuma-akhawunti atholakele ngemibhalo enembile nokukhishwa kwecala.
Ukukhishwa kwe-Charge kuhlanganisa ukuxhumanisa okufanelekile kwamakhodi wezokwelapha kumasevisi kanye nezinqubo ezenziwa ngesikhathi sokuvakashela isiguli. Indawo ngayinye yomtholampilo idlala indima ebalulekile ekufinyeleleni kokubhala kwekhodi kanye nokunemba kokukhokha. Kukhona inamba enkulu yezindawo ezifaka ukukhokha ukuthunjwa, kufaka phakathi, kodwa kungagcini ku:
- Ukunakekelwa okuphazamisayo
- Ukuphathwa kwamacala
- Ukunakekelwa Okubalulekile
- I-Laboratory
- Ukubeletha
- I-Medical-Surgical Unit
- Impilo yengqondo
- I-Nuclear Medicine
- Ukuphathwa kobuhlungu
- Izingane
- Imithi
- Ukwelashwa Kwemvelo
- I-Radiology
- Ukunakekelwa Okulimazayo
7. Ukuphathwa Kwempilo
Ukwaziswa kwezempilo kwezempilo kuyinkqubo yokugcina, yokugcina nokuthola ulwazi lwezempilo ngesineke ngokuhambisana nezidingo zikahulumeni, uHulumeni, nezidingo ezigunyaziwe. Kunemithwalo yemithwalo eyishumi ngaphakathi kohlaka lokuphathwa kolwazi lwezempilo.
- I-Coding yezokwelapha
- Ukunyatheliswa Kwezokwelapha
- Ukwelashwa Okudingekayo
- Ukusekelwa kwabasebenzi bezokwelapha
- Iqoqo Lamarekhodi Ezokwelapha
- Ukugcinwa kwamarekhodi wezokwelapha
- Ukufakela nokubuyiswa
- Ubumfihlo nokuphepha
- Ukukhishwa kolwazi
- Ukugcina ukufihla
8. Amasevisi Ezezimali Eziguli
Izinkonzo zezeMpilo ezibekezelayo ekugcineni zibophezele ukukhokha nokuqoqwa kwama-akhawunti okutholakele ehhovisi lezokwelapha.
Inqubo yokukhokha yezokwelapha idinga ulwazi oluphelele lwababakhokhisi bomshuwalense kanye nemithetho nemigomo yomkhakha wezempilo. Abadayisi bezezimo zezokwelapha banesibopho sokuthumela ngesikhathi esifanele izicelo zezobuchwepheshe noma zezokwelapha ezinkampanini zomshuwalense kubandakanya amahhovisi odokotela, izibhedlela, amakhaya asebekhulile, noma enye indawo yokunakekelwa kwezempilo.
Imiphumela eqoqayo yokulandelela amaqoqo ekuxazululeni okusheshayo kwezimangalo zehhovisi lezokwelapha. Ukulandela okumangalelwa kufanele kuqale ngokushesha ezinsukwini eziyisikhombisa kuya kwezingu-10 ngemuva kokuthi isimangalo sakho sithunyelwe ngenkokhelo. Imizamo esheshayo yokuthola izimali ezikhokhwayo ngeke inciphise kuphela ama-akhawunti akho atholakele kodwa ikhulise nokugeleza kwemali.
Ukusebenza okwanele ngokuqeqeshwa okuqokelelwa kahle kuzohlinzeka ngomphumela oyifunayo kwisigaba sokuqoqa umjikelezo wemali. Abasebenzi behhovisi lezokwelapha kufanele baqaphele izinyathelo eziyisisekelo ezidingekayo ukuze kulandelwe ukulandelwa kwemali yomshuwalense.
Ukubambisana nokubambisana kwazo zonke izindawo eziyisishiyagalombili kuyizingxenye eziyinhloko zokuphumelela kokuphathwa kwezimali ezifanelekayo. Nakuba kunezithiyo ezingalindelekile ezingathinta isikhathi sokuqoqa i-AR, kuyinhloko yobuholi ukukhomba nokulungisa lezi zithiyo ekuphumeleleni kwenhlangano.