Ecosystems

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School

Western Governors University *

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D391

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Health Science

Date

Jan 9, 2024

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docx

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Uploaded by GrandEmuPerson435

There is no required page length for this paper, but I do see on average around 3-5 pages. Here are the notes for what will need to be discussed in Task 1: A.1 – Standards (choose one of the three but cover both physicians and hospitals for the one you choose) and discuss the impact on the physician and hospital reimbursements if they do not become a participant. This is a financial impact with not getting reimbursements if they do not participate fully with Medicare. This is in the course textbook during study, section 4.4, and click on the link for the textbook, Health Information Management . It will take you to Chapter 1, page 28 in the 6th edition of the book Please discuss just one: Licensure – Very simple! - Both physicians and hospitals must be licensed by the state where they practice. It is against the law to not have a license. If they do not have one, then they cannot participate with Medicare or anyone else! Certification – Medicare will certify physicians and hospitals for the scope of medicine they are allowed to practice and file claims for. In addition, certification with hospitals involves having state surveyors come it to evaluate the hospitals and upon completion, they are deemed certified. Once done, they can participate with Medicare and receive reimbursement as a provider. Accreditation – hospitals can voluntarily seek accreditation by an entity like Joint Commission to participate with Medicare and receive reimbursements. Once complete, they can sign the conditions of participation. Physicians cannot seek accreditation. A.2.a. Clinical Quality Reporting Systems - discuss the impact on the physician and hospital’s reimbursements if they do not use the required reporting systems. An overview is in 4.1 in the course of study with p.71 CMS clinical quality basic measures Medicare announces participants to improve access. Quality of care in rural areas. After the overview, please discuss the specific examples below: MIPS – Merit Based Incentive Payment System – physicians (also on page 312, Chapter 10 in the HIM textbook). https://qpp.cms.gov/mips/overview https://www.practicefusion.com/quality-payment-program/what-is-mips/ AND VBPS or Value-based Purchasing Systems for hospitals (also on page 312, Chapter 10 and 616, Chapter 20 in the HIM textbook): https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/Value-Based-Programs/HVBP/Hospital-Value-Based- Purchasing.html
A.2.b. Reimbursement: Chapter 7, page 212 (the ebook page number in the lower left corner) in Health Information Management Book via this link in 5.2 in the course of study: Chapter 7 (Reimbursement Methodologies) Medicare Part A for hospitals with Prospective Payment Systems Medicare Part B for physicians with RBRVS formula Four questions to answer: oWho files the claims? oWho receives the reimbursements? oIs there an allowable fee schedule? Is there a contractual write-off? https://www.americanmedicalcoding.com/contractual-adjustment-medical- billing/ Other helpful link https://www.medicareinteractive.org/get-answers/medicare-covered- services/outpatient-provider-services/participating-non-participating-and-opt-out- providers Discuss the impact on the physician and hospital’s reimbursements if they do not become a participant and they can then balance bill the patient. A.2.c. Patient Access to Care (see attached articles 5 and 6 in the welcome email attachments) and summarize the following issues that may affect a patient being able to find Medicare Providers: Physicians Opting Out of Medicare due to regulations and red tape, thus impacting access. Shortage of PCPs coming out of U.S. Medical Schools, thus lowering the number of physicians for Medicare and impacting access. Most PCPs are Medicare Providers Medicare’s reimbursement to physicians is low. Here are the links for them also: https://www.marketwatch.com/story/americas-1-million-doctor-shortage-is-right-upon-us-2016- 04-01 http://aspe.hhs.gov/health/reports/2013/PhysicianMedicare/ib_physicianmedicare.cfm Discuss how Medicare pushes physicians to opt out and to look to something other than Primary Care Provider roles. B.1 Role of Health Information Management Professional Name specific HIM role such as a medical coder or reimbursement specialist. Show the effect Medicare has on that specific role. For example, in order to submit claims to Medicare, a coder needs to know the various coding systems
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