Case Study: Affordable Health Care

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

Healthcare is often driven by consumers and insurance companies; there is strong pushes for insurance companies to start paying better through Patient Care Medical Homes (PCMH) or Accountable Care Organizations (ACO) rather than paying at a per-visit basis (Hamlin, 2015). With PCMH or ACOs payment is made on a continuum of care, encouraging the provider to be involved in all aspects affecting health of the patient (Derksen, & Whelan,

Now a statute, the physician/hospital pay for quality, not quantity, public law number: 114-10 signed April 16, 2015 also referenced as H.R.2 —1st Session of 114th Congress (2015-2016), sometimes called the “Permanent Doc Fix” 04/14/2015 : Passed Senate; 03/26/2015 : Passed House (Medicare Access and CHIP Reauthorization Act of 2015, 2015), which defines the payment and reimbursement reform to doctors treating patients with Medicare. This extensive reform includes the CHIP program insuring children and those families that don’t qualify for Medicare but are unable to afford private insurance and is funded by the federal government and individual states.

Prior to September 2011, Medicaid Managed Care Organizations (MCOs) paid FQHCs a fee-for-service rate and HHSC reimbursed FQHCs the difference between the rate paid by the MCO and the FQHC PPS rate in quarterly wraparound payments. Pursuant to budget riders starting in the 2012-2013 General Appropriations Act, and continuing through the current appropriations bill, HHSC Rider 62 (HB1, 84nd Regular Session, 2015), MCOs were required to pay the full PPS rates to FQHCs up front. The stated intent of Rider 62 was to reduce HHSC administrative costs. The administrative cost was associated with the Texas Medicaid and Healthcare Partnership (TMHP), an HHSC contractor, calculating and disbursing the wrap payment to each FQHC. By moving responsibility for the wrap payment to the MCO, the administrative cost to HHSC was eliminated. Rider 62 did not contemplate a reduction in appropriate FQHC utilization.

Throughout the early 1980’s and 1990’s the Federal Medicaid program was challenged by rapidly rising Medicaid program costs and an increasing number of uninsured population. One of the primary reasons for the overall increase in healthcare costs is the

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.

In the past several years, there have been several changes in economic policy at federal and state levels. The two economic policies that present to be the most precedent for healthcare leaders with concern to facility reimbursement are the Affordable Care Act (ACA) and the switch from volume to value reimbursement. First, there is the ACA policy, which have affected healthcare facilities and their reimbursement methods. In fact, ever since this policy was implemented, provider reimbursement has started to decrease in terms of fee-for-service payments (The Common-Wealth Fund, 2015). In other words, the intention of this policy was to provide budget relief to the government payers as well as giving providers an incentive to provider patients with great quality of care.

Implementation of the ACA would require an extensive expansion of the Medicaid program to low income adults in each state.³ The Congressional Budget Office projects that a previously 30 million uninsured Americans, approximately 92% of the legal, non-elderly population, will have coverage by 2022.³ The federal government will pay for 100% of the costs of expanding Medicaid programs until 2016, and then gradually fade their contribution to 90% by 2020.³ Currently, expansion of the Medicaid program is voluntary and several states have stated that they intend to turn down their share of the billions of dollars that has been made available to each state solely for the expansion of this program.³ States deciding to not expand their Medicaid program will not only exclude many poor, vulnerable families from access to an important health care program, but will also exclude themselves from an economic stimulus for their state and thereby decrease the strength of their health care delivery systems by not allowing them to be more financially stable for the long

Healthcare reimbursement systems within the United States are a complex structure for obtaining payment for services rendered. The healthcare system officers are required to understand the ordinary principles of the payer system. Understanding the rules, and keeping up with the continuous changes will allow the providers, physicians, and facilities to gain an advantage in this growing healthcare domain. Both private and commercial insurance companies provide a diverse menu of choices to customers. All third-party payers create interest in decreasing healthcare costs and improve control access to the not needed services. This paper will address the complexity of the healthcare reimbursement systems in the United States. Additionally, the research

HCA is a healthcare provider that was established in 1968. Their main focus is on offering cliental with a number of different services to include: inpatient, intensive care, outpatient, diagnostic and emergency services. To achieve these objectives they operate a variety of facilities such as: outpatient, psychiatric, surgery centers, freestanding emergency care facilities, diagnostic / imaging centers and comprehensive rehabilitation / physical therapy centers. They are structured to create increasing earnings for its policy and shareholders. This is achieved by contracting with private doctors to deliver services to its preferred providers members. At the same time, they receive fees from these entities and they negotiate lower group rates.

The former Texas Governor Rick Perry states that “the government’s obligation to help people without health insurance is limited,” and that by allowing Texas to expand Medicaid would cause “staggering costs [to be] handed down to generations yet unborn” (Del Bosque, 2013). Just as some disagree with Texas’ decision, there is many that support the decision made. The plan that the federal government came up with to cover the costs of expansion that is mentioned before would cost Texas $1.2 billion in the year 2022 (Garrett, 2013) John Davidson of the free market-oriented Texas Public Policy Foundation states that, “until Medicaid is fundamentally reformed, it’s reckless to expand it.” (2013) By expanding Medicaid, the government is threatening things such as public education by taking money from its budget (2013). As it began, the federal government said they would pay at least 90 percent of expansion costs (2013). But the President’s budget has already proposed change, causing Texas to have more strain on state budgets (Senger, 2012). Politicians are usually really good at saying they will do one thing, and then doing

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

Department of Health and Human Services. CMS oversees many federal healthcare programs, including those that involve health information technology such as meaningful use incentive program for electronic health records. This business model shifted traditional fee-for-service payment method in the direction of models where the provider payment is paid in advance. In the fee-for-service model, the provider is paid less whereas payer benefits only if few resources are consumed. CMS payment methods are like private insurers which bring more risk to the

If the Centers for Medicare & Medicaid Services (CMS) change their payer regulations and accreditation requirements, hospitals would need to accommodate their requests for continued supplemental payments. In other words,

You may know that recently our company has adopted new health care policies due to the recent implementation of the Affordable Health Care Act. FixIt would like to inform you of some of the changes made in response to this new bill. Through our new health care provider we will be able to provide the same benefits for a lower price point, 15 percent lower to be precise. The only difference with our new provider is we will no longer be able to provide exercise, weight-loss, and smoking-cessation classes. We know many of you appreciated these class and the sudden cancelation is disappointing, but these classes are not being entirely dissolved. Instead we will now be providing these classes at an employee discount rate of $35/month at the nearby