Cmgt 430 Week 5 Paper

First implemented in 1985 by Aetna (previously U.S. Healthcare), P4P programs were used to reward top performers and improve outcomes (Bruno, 2012). The incentives were meant to improve the quality of patient care by basing incentives on patient outcomes. Conversely, fee-for-service reimbursements are based on the treatments and set limits on the amount reimbursed for services. Because of these limits, incentives for use of pharmaceuticals and non-invasive procedures can impact how physicians practice.

"Medical coding professionals provide a key step in the medical billing process. Every time a patient receives professional health care in a physician’s office, hospital outpatient facility or ambulatory surgical center (ASC), the provider must document the services provided. The medical coder will abstract the information from the documentation, assign the appropriate codes, and create a claim to be paid, whether by a commercial payer, the patient, or CMS." (Aapccom, 2015) It is very important that billing coders have a full understanding of how to properly use medical codes to prevent denial of claims submitted.

H. (04/2015). Comprehensive Health Insurance: Billing, Coding & Reimbursement, VitalSource for Allen School of Health Sciences, 1st Edition. [Bookshelf Online]. Retrieved from https://online.vitalsource.com/#/books/9781323131503/

Physicians and other facilities are paid by insurance companies, including Medicare and Medicaid, based on the procedure (CPT) code they submit. These codes must be accompanied by the correct diagnosis or ICD-10 codes.There must be a valid reason for a medical encounter for the physician to be paid, such as pain, refills for medications, or a follow-up for such diseases as diabetes or any chronic condition. If you just submit the CPT or ICD-10 code separately then you will not be paid as both support each other. So it is vital that a medical biller and coder be aware of these rules and how to complete the claim forms properly.

Texas 1115 Waiver 1115 -- payments that help hospitals with the costs of uncompensated care

Up-Coding Services: Billing of government and private insurance programs is done using a complex series of numerical codes that identify the specific procedure or service being performed. These code sets can include: the American Medical Association’s Current Procedural Terminology (“CPT”) codes; Evaluation and Management (“E&M”) codes; Healthcare Common Procedure Coding System (“HCPCS”) codes; and International Classification of Disease (“ICD-9”) codes. Government health care programs assign a dollar amount it will pay for each procedure code. Up coding occurs when a health care provider submits of a claim for health care services, treatments, diagnostic tests or items that represent a more serious and more expensive procedure than that which actually was performed. Up coding can be a violation of the Federal False Claims Act.

One of the major goals of the ACA is to improve quality of care by using a value-based system. Nationwide, nearly 3,500 short-term acute-care hospitals are reimbursed under the Inpatient Prospective Payment System (IPPS). Within the IPPS is the Hospital Value-Based Purchasing Program is (VBP). This program “rewards acute care

Fee for service indemnity plans are essentially health insurance plans in which the consumer may choose any provider or hospital that they want to use; however, these plans are typically more expensive than other plans (Mukherji & Fockler, 2014). The fee for service plans pay only for services rendered, typically using the CPT coding system (Reimbursement, 2016). The indemnity plans will require the provider to bill the insurance company for services rendered (Zuvekas & Cohen, 2016). Typically, the insurance company will pick up 80% of the patient’s bill and the patient is responsible for the other 20% (Zuvekas &

Which type of health insurance pays part of all of the surgeon 's fee for an operation

Our company recently enlisted the services of Sajini Thomas of Global Integrated Reimbursement Services, Inc. to obtain Federal recognition of our product for a specific HCPCS code. Ms. Thomas’ thorough understanding of the Medicare

These payments include cost and markups for the services provided, and are used in conjunction with per case constraints (Murray, 2009). Revenue constraints, such as case constraints allow the system to control hospital revenue through control encounter utilization, adjust for case-mix, and align incentives across payers and hospitals (Murray, 2009). Annual adjustments for inflation and uncompensated care markups ensure the systems’ ability to equalize the markup for

In an effort to encourage hospitals to promote improvement of patient safety with the use of standardized protocols, CMS adopted the non-reimbursement policy for certain conditions called "never events". This limit the ability of the hospitals to bill Medicare for adverse events and complications. The non-reimbursable conditions apply only to those conditions which could be prevented with the use of evidence-based guidelines. “The list of “never events” covered under the CMS payment policy falls into three categories: surgical events, medical products and devices, and case management” O’Rourke & Hershey (2009). Examples:-

When this provider bill with rev codes, they are receiving a payment but then they bill out-patient services they’re receiving a denial G18. Do you know how this provider is set-up to bill?

The compliance process is set up to ensure the maximum appropriate reimbursement for health care claims. Correct billing and coding are directly linked to correct documentation by a physician. Also, to complete documentation, linking the correct code to the correct diagnoses is a must. This step is vitally important in reducing compliance errors. Second, the implications of incorrect coding can have a domino effect and will ultimately cause many people in the chain of events to go back, review, correct the errors, and resubmit the claim. This could also cause the patient and payer more money or cause a claim to be denied.

I agree Roshanda, the purpose of coding is to ensure accurate reimbursement for services that were provided to a patient. Coding works the same way as the medical terminology a physician would learn. Physicians need to know the proper medical terminology for procedures, diagnosis, and body parts etc in order to communicate with other physicians and healthcare providers. Well it works the same way with the insurance companies. Insurance companies uses coding as their way of communicating with each