Billing Of Services, Revenue Cycle, And Reimbursements

Obtaining reimbursement for services provided is a necessity for the survival of many health care organizations. This paper will explain, in my opinion, why the Centers for Medicare and Medicaid Services (CMS) are involved in this development and how it affects the American public. I will offer a suggestion to ensure meeting policy and procedure. I will finish by discussing three ideas listed on the CMS website.

Payment-determination bases are composed of three factors: cost, fee schedule, and price related. In a cost-payment basis the provider’s cost is the main method for payment (Cleverley, 2010). It is essentially a way to formulate fees for medical services. Prior to this practice, medical cost for medical services differ from state to state, which led to a variety of fee schedules. According to Brumley (2015), the varying fee schedules were inefficient for Medicare; therefore, to solve this issue Medicare linked fees to the actual cost of providing specific services. This became a component of the Section O of Title 42 in the code of Federal regulations; which sought to describe the different costs that can be included when it comes to calculating medical fees. The goal was to structure medical fees on a more cost-reasonable basis.

In 1983, the Medicare prospective payment program was implemented which allowed hospitals to be reimbursed a set payment based on the patient’s diagnosis, or Diagnosis Related Groups (DRG), regardless of what treatment was provided or how long the patient was hospitalized (Jacob & Cherry, 2007). To keep the costs below the diagnosis related payment, hospitals had to manage efficiently the treatment provided to a client and reduce the client’s length of stay (Jacob & Cherry, 2007). Case management, or internal case management “within the walls” of the health care facilities was created to streamline costs while maintaining quality care (Jacob & Cherry, 2007).

The high cost associated with Medicare requires approaching health care reform from an intentional perspective. One approach to help achieve integrated and efficient care is to foster accountability for quality and cost through performance measurements and “shared savings” payment reform. The approach provides a practical and feasible method for providers and organizations to improve their current revenue cycle processes, while maintaining provider incomes and reducing overall health care costs.

With PPS Medicare has developed diagnosis-related groups (DRGs) that groups clinical conditions together and based off the DRGs of a patient it then in turn provides a reimbursement rate to give the provider (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/acutepaymtsysfctsht.pdf). The theory behind this style of reimbursement is that it give the hospital an incentive to efficiently treat a patient and quickly discharge the patient without wasting any unnecessary medical resources.

Under the Affordable Care Act, traditional fee for service reimbursement will be methodically phased out over time and be replaced by quality of care reimbursement; therefore, the focus of primary care will be shifted from the actual treatment of patients

With the Centers for Medicare and Medicaid (CMS) providing coverage for over 100 million citizens in the United States and being the largest care delivery system, it is hard to ignore their presence in the ever changing health care delivery system. Some say, that where Medicare goes, private payers will follow. Today, hospitals, health systems and other providers have been highly influenced by Medicare. Medicare, Medicaid, the Children 's Health Insurance Program, and the Health Insurance Marketplace are leading the way in the movement to provide coverage under this system. As the Affordable Care Act is ironed out, there are still billions of dollars being spent within the Medicare/Medicaid programs. In an effort to try and combat some of the overwhelming costs of these programs, the Accountable Care Organization (ACO) Model has slowly begun to integrate itself into the Medicare/Medicaid system. This has brought about some interesting changes with reimbursement, cost containment, and quality of care. Each making slow shifts towards change and developing new systems of providing quality health care.

For hospitals, the predominant unit of payment for inpatient care is often a per day basis. The hospital receives a fixed daily payment rate per enrollee patient regardless of the services provided. However, it can have mixed option in the hospitals including pay a per diem rate for all inpatient services, as well as case rate pay for DRGs; most often high costed surgeries get paid by case basis rate. Under this case based arrangement, providers must take into consideration outlier and inlier cases. These cases can be reimbursed on a percentage of

Prospective payment system is a “method of reimbursement in which payment rates for healthcare services are established in advance for a specific time period.” These rates are based on the average usage of resources for those certain types of healthcare. The prospective payment system puts the liability on the healthcare organization because the cost of the healthcare procedure can be more expensive than the average cost. Therefore, healthcare organizations need to be methodical with the way the treat their patients, use as little resources for the best quality of care. There are many prospective payment systems; there is inpatient, acute-care, inpatient psychiatric facility, home health, outpatient, long-term care, rehabilitation, and nursing facilities.

For the most part, I can correlate my findings with this week’s reading and lecture. With the introduction of ACA, emphasis on the quality of healthcare and patient safety has grown significantly since reimbursement is directly linked to it. ACA has enacted various provisions to improve the quality of care and reduce the cost of healthcare. These provisions are, “incentive to reduce Medicare readmissions, incentive to reduce hospital-acquired conditions, pay for value programs for hospitals and physicians and bundled payment” (Blumenthal, Abrams and Nuzum, 2015).

Medicare & Medicaid administers a comparative Billing Reports program (CBR program) that details comparative data on how billing patterns vary from providers in the same area. This can be useful information for all NPs in practice. An interesting Web site to review to learn about and keep up-to-date on Comparative Billing Reports (CBR) can be found at www.cbrinfo.net/about-us.html. Contractors who manage the billing information are responsible for conducting the statistical analysis central to the data contained in each CBR, developing and disseminating the CBRs, ensuring data integrity and privacy, and providing customer service and educational outreach to providers. Comparative Billing Reports are like the Program for Evaluating Payment

For US hospitals tattered by competition, trying to be all things to all patients is no longer a feasible strategy. One way hospitals can more successfully contend with smaller, more focused competitors is to systematize themselves by service line, focusing on building first-rate capabilities in just a few clinical areas. Hospitals that do well with this strategy can garner great fiscal benefits while enhancing their capability to serve their communities. Choosing the right service lines to stress requires a greater understanding of a hospital's finances and competitive environment. Hospitals also need to renovate the management of both strategic and nonstrategic service lines in order to be successful (Service-line strategies for US hospitals, 2008).

Increase total revenue without raising service rates. More service at the same price. The hospital should focus on shrinkage of the hospital stay and other procedures in the inpatient service and vice versa, to widen some types of outpatient services which require less stay time at the hospital.

Health Care is an industry that constantly changes. For that reason, the revenue cycle process in health facilities constantly changes. As a result, many challenges in Revenue Cycle Management arise. Revenue Cycle Management (RCM) is defined as the process of "all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue” (Amatayakul, 2006, p.46). RCM is a complex process that requires tools and properly trained staff. Some of the challenges RCM can face are losing coordination and accountability of health care services. Health care services is more than just medical attention, it consist of care and financial management. Therefore, RCM leaders have come up with solutions to improve coordination and accountability in Health Care.

The purpose of the current quantitative, ex post facto, correlational research study was to describe a correlation between allied