Case 6 Reimbursement In Health Care

It is important to follow payer guidelines when completing a claim form; otherwise, reimbursement will be delayed until the form is corrected.

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

In 2012, the ACA found an excessive amount of readmissions of patients that were hospitalized within 30 days for the same medical conditions. This factor viewed under the ACA as a quality issue and CMS implemented value-based incentive payments based on performance in a set of quality measures. The plan is to implement a pay for performance (P4P) in formulas used by Medicare to reimbursement providers. “The objective is to link reimbursement to quality and efficiency as an incentive to improve the quality of health care, as well as reduce system-wide costs” (Shi and Singh, 2015). In addition to the P4P, nonprofit hospitals also focus on continual improvement, data and cost containment throughout the organization (Adamopoulos,

Unit 2 AssignmentKelley WhitcombKaplan UniversityHI215-01: Reimbursement MethodologiesProfessor Kathleen SobelJuly 20, 2015Medicaid is one of the biggest insurance plans you can get in any state. In the state of Indiana, it is based off of your income. There is a certain amount (income) you have to make to determine if you will receive Medicaid or Healthy Indiana Plan (HIP). HIP is still a form of Medicaid, but you would have to pay monthly cost for it and have certain set of co-pays for certain services that is needed. HIP Plus is the recommended plan for members as it provides health coverage for a low, predictable monthly cost. HIP Plus also covers dental and vision services. If you do not pay your monthly payment you can be removed from

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.

Quality physician documentation is not only essential to providing superior clinical communication, but also allows for the delivery of useful data that “supports quality metrics, acuity of care, billing, and accurate representation of medical conditions” (Rosenbaum et al., 2014). The Centers for Medicare and Medicaid Services (CMS) uses a system to classify Medicare patient’s hospital stays into various groups in order to facilitate payment of services called Medicare Severity-Diagnosis Related Group (MS-DRG). Some payers also use all patient refined (APR)-DRG reimbursement systems. MS-DRG groups are outlined by a specific collection of patient characteristics which include areas specific to the “principle diagnosis, specific secondary diagnoses,

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.

The process for medical billing involves a health care provider submitting, and following up on claims with health insurance companies in order to receive payment for services rendered; such as treatments and investigations. Once the procedure and diagnosis codes are determined, the medical biller will transmit the claim to the insurance company. Most physicians have medical directors that review claims for patient eligibility. Physician reimbursement and the coding to support it are critically important to the sustained health of any physicians practice. Under the contract provisions the physicians are responsible for rendering the services to the patients. In the billing process physicians need to know how services are rendered.

The debate over non-profit versus for-profit healthcare organization has been ongoing, does one provide better care than the other? Do the operations of for profit perform better than the non-profit organizations? Are the criticisms about for-profit organization validated and is there proof? The goal is to examine those questions as well as offer options to improve the financial and operational performance of non-profit and for-profit organizations criticisms.

For profit providers look at health care as a business, with a financial bottom line producing profits that can be distributed to shareholders. Supporters of for-profit health care say that increased competition can produce a more efficient, effective, less expensive health care system. Since the 1980s, for-profit health care facilities have proliferated, including national hospital chains, health plans,

A flat salary can benefit the individual if the patient population declines or has a bad payer mix, or even when there are limits on the time or abilities. Alternatively, a base salary with incentives will benefit a provider if there is a good payer mix and a large enough population to guarantee the constant number of patients. Additional substantial issues involved in this decision include: the experience of the provider, type of practice, responsibility for filling the schedule (staff vs. the provider themselves), and method of calculating the amount reimbursed (billed vs. collected). Still other factors include business expenses such as an amount deducted for overhead or other salaries, cost of billing and billing responsibilities, and the frequency of payment

The major objectives of healthcare financial management include: generating income (which is the most important) because it is the financial status of the organization. It is important to ensure that revenues are exceeding expenses. After assets are invested in, they are meant to be used. They must respond to regulations and be accredited to qualify for loans, reimbursements, etc. Facilitate relationships with third-party payers because they are the ones helping with the bills. The health organizations must also influence method and amount of payment to avoid overpaying, when faced with capitated prices or prospective payments. Monitoring physicians is important because they are at the forefront of everything, so management must make sure that physicians’ orders are consistent with patient needs. Lastly, protecting tax status involves for-profit organizations trying to reduce tax liabilities, while not-for-profit organizations try to protect their tax-exempt

According to Berenson (2010), this payment model is considered to be the dominant payment model, with a representation of over 90% of primary care revenue. Although the use of this payment model has been problematic for primary care, many physicians who make use of the fee-for-service system have been greatly rewarded. The problems associated with fee-for-service are not only felt in the United States, but by doctors from around the globe. Such problems encountered by physicians have led to the reduction of quality care in the services provided. Compensation is based on the number and complexity of procedures the specialist performs.

One thing the health care organization has to key in is the community. The community in which they reside is the heartbeat of that organization. There is no way they can reach out to any other communities if they do not provide an adequate service to their local community. This is very important to have a good reputation of performing quality work at a fair price. This would insure your reputation stays intact. The community in which they serve must feel like this is the best organization for them and not consider any other choices. The organization in that community should have the best prices and really should be lower than any other organization in that area. In many cases the people closes to that organization do not shop around with the organization in the next town. What about the people who does? The thing is, the organization must have the best

Though they are not entirely comprehensive tools, a great deal can be learned about a hospital or other healthcare organization for-profit or not-for-profit from an examination of their annual financial documents (Finkler & Ward, 2006). The balance sheet and statement of revenue and expense can both yield valuable clues even in the absence of other evidence about changes that might be occurring in the organization, a definition of the type and degree of certain problems that it might be facing, and potential opportunities for improvement in performance that might exist (Finkler & Ward, 2006). Comparing two or more years' worth of financial information yields even more valuable insights, tracking movement in the hospital or other organization's ability to finance its activities and thus continue providing services at the same level, quantity, and scope as current operation.