Case Study : Directing And Controlling A Department

UHDDS is specific to hospitals that provide medical services for those covered by Medicaid and Medicare. As the federal government was becoming increasingly involved in healthcare, analysts realized the importance of creating a standardized system of medical coding that would be allowed for an easier comparison between hospitals. This data could also be used to compare the reimbursement rates of different hospitals for similar medical procedures, and thereby work towards a standardized system of reimbursement for the federal government nationwide. Standardization in reimbursement rates also helped hospitals move towards standardization in quality of

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,

The care delivery enterprise must be re-tooled so that it functions in a fee-for-value reimbursement environment as is has in a fee-for-service reimbursement environment. The Centers for Medicare and Medicaid Services (CMS) is leading the

The Arkansas Health Care Payment Improvement Initiative (“AHCPII”) is one part of the health care innovations the state has implemented with the aim of “increas[ing] health care quality and reducing the costs of care.” The AHCPII’s intent is to shift Arkansas’s payment system from “one that primarily rewards service volume to one that rewards desired outcomes, particularly with respect to quality and affordability.” Applying to Medicaid, Medicare, and private payers, payment innovation will move away from fee-for-service health care (where quantity all too often trumps quality) to pay for quality. In doing so, the hope is that Arkansas will gain a “new, sustainable model of financing” with the help of a multi-payer leadership and support.

Big Bend Medical Center is a full-service, not-for-profit, acute care hospital with 325 beds located in Big Bend, Texas. The bulk of the hospital’s facilities are devoted to inpatient care and emergency services. (Gapenski, pg. 27) The outpatient services section of the hospital is used by the Outpatient Clinic, as well as the Dialysis Center. The Outpatient Clinic, which makes up about 80 percent of the outpatient services section, has recently grown in volume and has created a need for 25 percent more space than it currently has. Moving the Dialysis Center to a new building was decide to allow expansion of the Outpatient Clinic. A change and focus on the allocation of costs has some department heads angry and claiming of

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.

According to Sebelius, (2013) article, Affordable Care Act Incudes steps to improve the quality of health care and lower cost for you and the nation as a whole. This means avoiding costly mistakes and readmissions, keeping patients’ healthy, rewarding quality instead quantity, and creating the health information technology infrastructure that enables new payment of models to work. North Carolina foundation for Advance Health Programs is a model to create and maintain a centralized tracking system to monitor and disseminate new model of payments and delivery of reimbursements. This

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.

The delivery system reform include: Mandates that the Secretary of Health and Human Services adopt value-based purchasing and payment methods for Medicare reimbursements for both physicians and hospitals. Creates incentives to reduce preventable hospital admissions. Creates a new Center for Medicare and Medicaid Innovation that will research, develop, test, and expand innovative payment and delivery arrangements. Encourages the formation of Accountable Care Organizations (ACOs) that allow hospitals and doctors to work together to manage and coordinate care and provides that these ACOs will receive a share of the savings they achieve for Medicare

The CMS reimbursement rules for never events cause serious revenue loss for the hospitals, hence a shift in the patient care delivery model in inpatient facilities is required. The goal of this rule is to motivate hospitals to accelerate improvement

The MPHFP enables certain rural hospitals to be licensed as Critical Access Hospitals (CAHs) that receive cost-based reimbursement from Medicare in return for limiting their services (Rural Assistance Center- CAH Frequently Asked Questions, 2012). Under costbased reimbursement, health care providers receive reimbursement based on actual costs incurred which is a more generous reimbursement method than allowed by the prospective payment system (Gapenski L, 2009). However, only those providers that fall under the following categories are eligible to become CAHs: currently participating Medicare hospitals; hospitals that ceased operation after November 29, 1989; or health clinics or centers (as defined by the State) that previously operated as a hospital before being downsized to a health clinic or center (Department of Health and Human Services, 2013). A Medicare participating hospital that wishes to convert to a CAH, has to meet certain criteria including (Department of Health and Human Services, 2013):        Be located in a state that has established a State rural health plan for the State Flex Program; Be located in a rural area or be treated as rural under a special provision that allows qualified hospital providers in urban areas to be treated as rural for purposes of

Doctoral level director with over 10 years of cross-sector leadership; leveraging strategic partnerships, launching high-impact programs and building resourceful organizational systems. Reflects continual advancement, and consistent achievements in driving innovative strategies, programs and initiatives that produce dynamic business results.

It has not been easy for Baylor Scott & White Healthcare to travel this journey, as it had to align its policies to the national health care priorities and embrace a slogan STEEP to provide quality healthcare to its clients. The organization bears a high quality strategy that is well spelt out in its vision and mission. The organization has worked to ensure that all the stakeholders make quality healthcare a priority. In other words, the organization has worked hard to link performance management incentives to clinical indicators and in the end create a multidisciplinary healthcare improvement operations team that can function across all

Credentialing to perform procedures in the GI lab is of importance to all physicians and non-physicians in our community. It must balance the needs of the community to accessible care with the need to provide high quality care that is safe, effective and consistent with community standards. Providing this balance between access and quality is the function of the Credentialing Committee of the hospital.

On the issue of timeliness, the PA IEB Representative RH testified that the Appellant was issued a notice on July 20, 2017, again on August 16, 2017 based on the Appellant’s request, and then again on September 13, 2017, based upon the Appellant’s request. The PA IEB’s position is that the appeal is untimely filed as the notice was issued three times before receiving the appeal on September 25, 2017.