| Course | HIM 600 Managing Compliance |
|---|---|
| Module | Module 7 |
| Paper type | graduate milestone on responding to compliance findings and corrective action |
| Length | About 1,030 words, 6 pages |
| Format | APA 7 student paper |
| School | Southern New Hampshire University |
| Program | MS Health Information Management |
| Updated | October 2026 |
Free sample paper for HIM 600 Module 7
Final Project Milestone Three: Paying Back and Fixing the Cause. Response and Corrective Action at Sawtooth Bone and Joint
[Student Name]
Southern New Hampshire University
HIM 600: Managing Compliance
Final Project Milestone Three
[Instructor Name]
[Date]
The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.
Final Project Milestone Three: Paying Back and Fixing the Cause. Response and Corrective Action at Sawtooth Bone and Joint
Finding errors creates obligations. Once Sawtooth Bone and Joint, the composite Idaho orthopedic practice in this project, learned from its record review that 18 of 40 top-level office visits and 11 of 20 injection visits billed with modifier 25 were not supported, it could no longer treat those claims as uncertain. This milestone sets out the practice's response: investigating the scope of the problem, returning money it was not entitled to, deciding whether any matter must be disclosed, correcting the causes and checking that the corrections hold. Federal guidance describes responding to detected problems and developing corrective action as an element of an effective program, and it stresses that a response should address root causes rather than only the individual errors (U.S. Department of Health and Human Services, Office of Inspector General [HHS-OIG], 2023).
Investigating the Scope
The record review was a probe, so it shows that a problem exists but not how large it is. The compliance officer, the billing manager and outside health care counsel met within a week of the findings. Counsel advised that the practice must make a reasonable, timely effort to learn whether the same errors extend to earlier claims. The committee therefore approved a statistically valid random sample of office visits billed as 99215 and injection visits with modifier 25 from January 2022, when the group adopted its current templates, through the review period. An outside coding firm will draw and review the sample, under a written sampling design, which lets the per-claim error found in the sample be projected across every claim in the period. Counsel directs the work so that legal advice about the results is protected. The review is scheduled to finish within ten weeks, well inside the period federal rules allow for a good-faith investigation before an overpayment must be returned.
Refunding What Is Owed
For the 29 claims already found unsupported, the overpayment is the difference between what was paid and what the documented level or service supports. For the 18 office visits, that is the difference between the 99215 payment and the 99214 or 99213 payment. For the 11 modifier 25 claims, the separately billed visit should not have been paid at all. The billing manager calculated each amount by payer. Medicare and Medicaid overpayments will be returned through the contractors' voluntary refund process with an explanation of the reason and the claims affected, and commercial payers will receive refunds under their contract terms. If the look-back sample shows a pattern, the extrapolated amount will be refunded the same way.
Refund or Disclosure
Not every overpayment needs to be reported to federal investigators. Ordinary billing errors, such as levels that are too high because clinicians misunderstood the guidelines, are corrected through refunds to the payer. The federal self-disclosure protocol is meant for conduct that may violate criminal, civil or administrative law beyond a simple overpayment, such as kickbacks or knowingly false billing, and disclosure under it can lead to a lower multiplier on damages than an investigation would (U.S. Department of Health and Human Services, Office of Inspector General, 2021). Nothing in the record review suggests intentional misconduct. Counsel will, however, review two matters before the refund decision is final: whether any clinician continued high-level billing after being told it was unsupported and whether the brace supplier's offer was ever accepted at any clinic. Either could change the answer.
Corrective Action Plan
Table 1 lists the corrective actions. Each has a single owner, a deadline and a measure that shows whether it worked. The actions target the causes found in Milestone One rather than only the clinicians whose claims were wrong.
Table 1. Corrective Action Plan
| Action | Owner | Deadline | Measure of success |
|---|---|---|---|
| Remove level suggestions from office visit templates | EHR analyst | 30 days | No template displays a suggested level |
| Default injection template to a brief pre-procedure note | EHR analyst | 30 days | Template change in production |
| Claim edit holding modifier 25 on repeat injections for review | Billing manager | 45 days | Edit active; held claims reviewed within 2 days |
| Guideline training with five-note coding test | Lead coder | 60 days | All clinicians tested; 80% pass or retrained |
| Prospective review for clinicians below 90% accuracy | Lead coder | Starts at 30 days | Two consecutive monthly samples at 90% or better |
| Copied documentation policy and color display | Compliance officer | 60 days | Policy signed by all clinicians; display active |
| Advanced practice billing rule and system check | Billing manager | 45 days | No visits billed under a physician without documented participation |
| Written decline of supplier staffing offer | Practice administrator | 7 days | Letter on file |
Note. Owners report progress at each monthly compliance committee meeting.
Clinician Feedback
Each clinician whose claims were sampled receives a private meeting with the lead coder to go through the specific notes, what supported or failed to support the code and how the note could have been written. Burks et al. (2022) identified the lack of a feedback system as one of the main reasons outpatient billing stays inaccurate, and Sawtooth's clinicians had never seen a coder's view of their notes. The meetings are framed as education. Only a clinician who continues the same errors after training and prospective review moves to the graduated consequences described in Milestone Two.
Proving the Fix Held
Corrective action is not complete until a later audit shows improvement. The compliance officer will repeat the same probe design three months after the training deadline and again at six months. The targets are at least 90% accuracy for top-level office visits and modifier 25 claims and no copied examination findings that contradict the assessment. If the targets are missed, the committee will revisit the causes rather than repeat the same training. Results, refunds and actions will be documented in a single file that shows the practice found the problem, paid back what it owed and fixed what caused it.
Conclusion
Sawtooth's response turns an uncomfortable finding into a record of good faith: a timely look-back under counsel, refunds by claim and payer, a reasoned decision about disclosure, corrective actions with owners and measures and re-audits to confirm the change. The final proposal will bring this response together with the program's structure and audit plan.
References
Burks, K., Shields, J., Evans, J., Plumley, J., Gerlach, J., & Flesher, S. (2022). A systematic review of outpatient billing practices. SAGE Open Medicine, 10. https://doi.org/10.1177/20503121221099021
U.S. Department of Health and Human Services, Office of Inspector General. (2021). OIG's health care fraud self-disclosure protocol. https://oig.hhs.gov/compliance/self-disclosure-info/
U.S. Department of Health and Human Services, Office of Inspector General. (2023). General compliance program guidance. https://oig.hhs.gov/compliance/general-compliance-program-guidance/
What the HIM 600 Module 7 instructions ask for
For the HIM 600 Module Seven milestone, the final project turns to what an organization does after it finds compliance problems. A typical submission runs four to five pages in APA 7 and covers investigating how far the problem extends, quantifying and returning overpayments, deciding whether a matter must be disclosed to a government agency, correcting root causes and confirming that corrections worked. Use the findings from your record analysis and the structure you designed in Milestone Two. Explain the role of legal counsel and why a probe sample may need to be followed by a larger review. Present corrective actions with owners, deadlines and measures, preferably in a table, and finish with a schedule of follow-up audits and the targets they must meet.
How this HIM 600 Module 7 final project milestone three example is built
Sawtooth Bone and Joint starts from 29 unsupported claims and a counsel meeting within a week. An outside firm draws a statistically valid sample back to January 2022, when the templates changed, inside the window for a good-faith investigation. Refunds are calculated claim by claim and payer by payer. The paper separates ordinary refunds from the federal self-disclosure protocol, naming two facts counsel must check first. Table 1 lists eight corrective actions, from removing level suggestions in templates to a written decline of the supplier's staffing offer. Private note-by-note feedback answers Burks and colleagues' point about missing feedback, and HIM 600 re-audits at three and six months aim for 90% accuracy.
Where the HIM 600 Module 7 rubric puts the points
Third-milestone rubrics in HIM 600 commonly reward an investigation that is timely and proportionate, correct handling of overpayments and refunds, an accurate distinction between refunding a payer and disclosing potential misconduct, corrective actions that address root causes, clear accountability through owners and deadlines and a plan to verify results. Strong papers involve counsel at the right points and explain why. Graders look for measures of success that are observable, such as an edit in production or an accuracy rate, rather than statements that training occurred. Treating clinicians fairly while still holding them to the standard shows maturity. A well-organized table and correct APA 7 citations for federal guidance round out the higher scores.
HIM 600 Module 7 help: the mistakes that cost points
Response plans in this course often slip by promising to fix errors without refunding the money already received, by sending every overpayment to the federal self-disclosure protocol, by listing actions without owners or deadlines or by ending at training without any follow-up audit. Some also treat a ten-claim probe as the final word on how much is owed. If your milestone uses a hospital, a payer audit result or a different set of findings from the course case, send them along with your earlier milestones and the response will be built around them. Notes on who has authority in your setting help assign realistic owners. Our HIM 600 milestones refund first, decide disclosure with reasons, assign every action and re-audit.
Get HIM 600 Module 7 written to your instructions
Send the HIM 600 Milestone Three guidelines along with your earlier milestones or audit findings. You will receive a response plan covering the look-back, refunds by payer, the disclosure decision, a corrective action table with owners, deadlines and measures and follow-up audits with targets, completed within 24 to 48 hours, with the first request free. The paper above is an original model document written by our desk, not a submitted student paper and not an official Southern New Hampshire University document.
More HIM 600 papers and related MS Health Information Management samples
- HIM 600 Module 1 Discussion: What a Compliance Program Is For
- HIM 600 Module 2 Fraud and Abuse Short Paper: Three Laws, Three Risks in One Practice
- HIM 600 Module 3 Final Project Milestone One: A Patient Record Analysis of Visits and Injections
- HIM 600 Module 4 Discussion: Copied Text in Clinical Notes
- HIM 600 Module 5 Final Project Milestone Two: Structure of the Coding Compliance Program
- HIM 600 Module 6 Auditing Short Paper: Choosing What to Audit and How Much
- HIM 600 Module 8 Journal: Why a Coder Stayed Quiet
- HIM 600 Module 9 Final Project: The Coding Compliance Program Proposal
- HIM 600 Module 10 Reflection: What Managing Compliance Taught the Writer
- HIM 500 Module 10 Reflection: The Informatics Leader's Role
- HIM 560 Module 7 Final Project Milestone Three: Evaluating Three Vendors
- HIM 550 Module 1 Discussion: What Fitness for Use Means for Hospital Data
- HIM 520 Module 6 Ethics Short Paper: A Physician's Request to Change a Note After an Adverse Event
HIM 600 Module 7 questions, answered
Where can I find a free HIM 600 Module 7 Milestone Three sample?
The complete HIM 600 Milestone Three paper appears on this page, covering refunds, a counsel-led look-back, the disclosure decision and an eight-step corrective action plan for an orthopedic group.
What should a corrective action plan include?
Each action should target a root cause and have a named owner, a deadline and a measure that shows whether it worked, followed by a re-audit to confirm the improvement.
When should a practice use the OIG self-disclosure protocol?
When conduct may violate fraud and abuse laws beyond a simple overpayment, such as kickbacks or knowingly false billing. Routine billing errors are usually refunded to the payer instead.
How are overpayments from coding errors calculated?
By comparing what was paid with what the documentation supports for each claim, and, when a pattern is found, by extrapolating from a statistically valid sample to the full set of affected claims.
Why involve legal counsel after an audit?
Counsel helps decide how far back to look, whether disclosure is required and how to protect legal advice, and can direct the look-back review so its findings are handled appropriately.