Healthcare Reimbursement in the Laboratory Tiffanee James November 14, 2016 Clinical Laboratory Science Management Georgia McCauley PhD, MBA, MT(AMT), CRA Introduction One thing that is consistent in healthcare is that healthcare is forever evolving. With the concept of evolution, one particular area that plays a major role in how the healthcare system evolves is revenue. In addition, healthcare facilities receive payment for the services provided. When exploring healthcare services reimbursement there are checks and balances that must take place. The healthcare provider orders services such as radiology and laboratory services that can be provided to a patient. Next, the facility sends a claim to the insurance company. Depending upon how the healthcare facility has coded the service and the documentation deeming the service as medically necessary determines if the facility receives payment for those services. This research is focusing on the laboratory in relation to healthcare reimbursement. To start, one must focus on the background of healthcare reimbursement and how it pertains to the laboratory. Next, it is important to look into the practices of reimbursement in the laboratory for the services provided including the rates that are currently enforced. Lastly knowing what fees will aid in the laboratory receiving the maximum reimbursement. The Background of Healthcare Reimbursement Complicated and always changing are a few characteristics that describe Healthcare
Patients who use peritoneal dialysis change their own cleansing solutions at home, usually about six times per day. This procedure can be done manually when active or automatically by machine when sleeping. However, the patient’s overall condition, as well as the positioning of the catheter, must be monitored regularly by nurses and technicians at the Dialysis Center (Gapenski, pg. 27-28). The Outpatient Clinic currently takes up 80 percent of the space it shares with the Dialysis Center. The recent growth in volume has created a need of 25 percent more space for the Clinic. Its large size compared to the Dialysis Center and its patients frequent use of other departments in the hospital are justifications as to why it was decided to move the Dialysis Center to another building. Big Bend Medical Center currently doesn’t have adequate space to house the Dialysis Center, so it was also decided to build a new 20,000-square-foot building. This expansion and move were went to benefit both departments and help increase patient volume. The goal of increased patient volume is expected, but the directors and other department heads did not agree with the new allocation of indirect costs. In the past, facilities costs were aggregated, so all departments were charged cost based on the average embedded cost regardless of actual age of the space occupied. Since many department heads considered this
4. Explain how the revenue from medical (pharmacy) supplies is currently handled for profit and loss reporting purposes. Is there a problem with the current system? Is there a better way of reporting this revenue? If so, what is it?
It is essential for an administrator to understand how private and government payers impact actual reimbursement. Government payers have a standardized benefit structure. The one benefit is that registration staff have an easier time calculating payment due (copayments) for service and can set up payment arrangements. Since the most significant proportion of funds coming into a healthcare organization is usually payments from third-party payers, therefore, it is critical to know how each reimbursement affect the others that come in. Healthcare organization may have hundreds of different payer’s relationships in the form of different contracts that have their own rates of payment that are usually different from other payers for an identical
It is important as an APRN to understand the rules and regulations of laboratory processes to better provide accurate testing for patients and because it is federal law. After reading and researching on Clinical Laboratory Improvement Amendments (CLIA), I can see how it is important for a future nurse practitioner to have this knowledge. There is a process that a clinic is required to understanding to obtain the correct certificate for performing lab testing. There are five different types of certifications: certificate of waiver (CW), Certificate for Provider- performed Microscopy Procedures (PPMP), certificate of registration (COR), certificate of compliance (COC) and certificate of accreditation (COA). I see that the certificate of waiver
The careful documentation and subsequent billing process within the course of a patient’s care is an important piece within the healthcare system as a whole. Proper documentation in a patient’s chart relating to any service or procedure is not only important for this patient’s future medical care, but for the facility to receive an accurate reimbursement for the services provided. Reimbursement is affected by every department within the hospital. Healthcare is a business in the long run, and inaccuracies within the reimbursement process will affect the financial stability of the hospital. If a department is mismanaging reimbursement data it could result
Fraud and abuse per our textbook can occur by unbundling and billing for a battery of services such as the laboratory tests separately as this was the issue referenced in the District Court Order of Ohio Hospital Association, et. al. v. Shalala. It was identified in number two of the footnotes that “Reimbursement was actually provided by a ‘fiscal intermediary,’ which contracts with the government to make determinations regarding coverage and payment (Ohio Hospital Association, et. al. v. Shalala, 1997).” This fiscal intermediary’s accountability in the case would bring about a discussion regarding if this was an innocent mistake, negligent conduct, or
The revenue cycle and reimbursements can be interrelated by the fact that sale of medicines generates revenue and reimbursement will affect the stock. The delivery of services to patient are also a part of reimbursements and revenue cycle. Since this facility primary financial resource relies on Medicare and Medicaid reimbursement. Quality of services seems to need improvements as better services to patients
Health care economics involves making plenty of choices. Individuals, groups, businesses, and organizations choose how to use resources . Economics and health care are linked, because health care professionals apply economics in their everyday professional activities. They are able to do this through resource allocation. Any health care organization has to plan out how they will use their resources to their advantage. Health care economics are able to incorporate terms like cost, quality, and resources. In this paper, I will compare these terms as they relate to health care economics. In this paper, I will also explain how they
Revenue determination is an important tool for health care organizations because it allows for efficient management of payment systems. This paper will look at the different components that form the payment-determination bases of revenue determination. Moreover, the difference between specific and bundled service payments will be discussed. Lastly, the three ways health care providers control their revenue function will be highlighted.
Payment for services will determine the advancement of technology. Research for cures, disease prevention, and new medications are examples that humans value. The involvement of the CMS affects many health care organizations. Even with the new health care reform, costs continue to rise and there remains a lack of access to many.
A challenge that the healthcare nation is facing is to provide the quality of care that is expected and obtain low healthcare cost. Working hand in hand with the private sector and government is in hopes of improving the quality of care that each patient deserves and maintaining the cost so that research can continue. The purpose of this paper is to look into relationships between healthcare cost and quality healthcare.
After discovering my passion for science and math, I pursue a career in Clinical Laboratory Science with enthusiasm. My desire to study this subject originates from the exciting and rapidly-moving subject area that is highly relevant to major issues facing society today. Clinical Laboratory Scientists play a crucial role in the healthcare field; in detection, diagnosis and treatment of disease in patients. My goal is to be involved in the latest advances in medical research and to constantly be expanding my knowledge about my field. On top of this goal, Clinical Laboratory Science remains a challenging, rewarding and inspiring topic that will motivate and shape my career for my entire life.
Payments for hospitals administrations is made by different means public and private, direct and indirect. Each of these techniques has diverse ramifications for doctor's hospitals money related health.
Among the growing shortages of doctors and nurses, are skilled laboratory professionals. These shortages can affect the quality of health care for patients in all health care organization. There has been such a tremendous growth for this profession and a great demand for laboratory testing. Currently, hospitals say it takes as long as twelve months to fill open laboratory positions. “The American Society for Clinical Pathology, which certifies lab professionals, says that average job-vacancy rates currently top 50% in some states.”(Wall Street, 2009) The information that laboratory professionals add to patient care is of the upmost importance and cannot be emphasized enough. Laboratory professionals have critical roles in patient care. Laboratory testing performed by the skilled professionals is the foundation for most all of the medical diagnoses and treatments made by physicians. “The general job responsibilities of clinical laboratory scientists and technicians, involve the collection and analysis of body fluids, tissues, and cells in order to diagnose and
I intend to study Medical Laboratory Science at South Dakota State University. My goal is to acquire my bachelor’s degree by completing four years in that program to earn a degree that would allow me to find a high paying career. An additional perk to my career path would be the fact that Medical Laboratory Science positions are highly in demand in South Dakota. I do plan to live and work in South Dakota after I graduate. I wish to gain a lot of experience out of this education, and gain the ability to help save lives by diagnosing and researching in a medical setting. Pursuing a college education would gain me a vast array of different career opportunities if I found that Medical Laboratory Science wasn’t for me, along with greatly increasing