Essay On Medical Billing

Moreover, we see that some providers are focusing on what providers do and how they get reimbursed rather than what the patient needs, which is a focus that does not prioritize quality of care and therefore does not align with the Triple Aim framework. The problem presented regarding this matter is that the health care system lacks a patient-focused care of medical conditions that puts patients and their health needs first. For example, when we think of provider reimbursement, it is not in the patient’s best interest for the system to only have a simple fee-for-service structure. A structure like this one will only lead to an increase of health care expenses. Also, it fails to incentivize high-value service, which also does not align with the Triple Aim framework health care providers should go by. It is very crucial for the health care system in the United Stated to find a better balance between medical groups reimbursement and patients needs in order to reduce the risk of overutilization.

Charges – This is the financial obligation made to a patient’s account for services rendered.

Enrolled patients use the global payment system. This means each member provides a fixed fee per month or year, irrespective of the amount of services

By evaluating the bill’s information, the case enters the MS-DRG category to determine the amount receivable by the hospital. The second step involves dividing the base payment into labor-related and nonlabor share. Mac adjusts the labor-related per an area's wage index applicable to a hospital's location (Reimbursement methodologies, 2016). However, adjustment of non-labor share for hospitals located in Hawaii or Alaska is per adjustment factor’s cost of living. In the third step, a hospital that serves a little portion of low-income patients receives a percentage add-on for every payment through PPS. The rate varies according to the low-income patients receiving the service, among other factors. Step four of IPPS involves offering a portion of add-on payment for every case payment through the PPS to approved teaching health facilities (Reimbursement methodologies, 2016). The last step analyses the costs sustained by hospitals to determine whether it qualifies for extra reimbursements. The aim of this extra payment is to protect a hospital from significant financial losses due to unusually expensive

The fee-schedule is the second component of the payment-determination basis, in which fees are pre-negotiated and have no correlation with the provider’s cost. For example, Medicare uses a fee schedule to

Fee for service, as the name suggest is a method in which the healthcare provider is paid individually for each and every service provided. In this method the numbers of services determine the amount of reimbursement. This is where the healthcare providers misuse their authority and either provides more services than what is needed or just manipulate the number of services provided. There are specific

In the medical billing revenue cycle, there are ten steps. The first step is patient preregistration where a patient schedules a visit and their insurance is either verified or on file. The second step is to determine the patient’s payment when visiting the provider and the reason for their visit. Next is to check the patient in upon arrival at their visit. This is to verify the insurance and the identity of the patient. The patient is checked out after seeing the provider and charges for services will show on the superbill. After this, the medical biller takes the patient’s superbill and creates a claim. From here, the biller must ensure that the claim is compliant with coding and arrangement. From here, the claim is prepared and finally

Any proposed policy to improve healthcare must address the current payment method, and the rising cost of healthcare. The common reimbursement method for healthcare services is the fee-for-service payment model. It requires providers to figure-out all incurred costs to render services for patients. Additionally, providers need to determine what is the insurer proposing to pay, which thought to reward quantity over quality. An alternative to this model is using a bundle

Conversely, fluctuating fee schedules also attribute to external influences that drive change. The topic of fee schedules are a substantial category of any healthcare reform bounced around the headlines at this time. Essentially, fee schedules are subject to what each state determines as sufficient for each diagnosis and associated treatment. “The fee schedule for many states hovers around 50 percent above the Medicare reimbursement rate. That state’s reimbursement rate under its fee schedule is just over 130 percent of the Medicare rate. That anomaly sends a message regarding both the competitiveness of the Medicare rate in Illinois and the related ease of obtaining medical services at that reimbursement level”. (Stahl, 2013). Fee schedule

In this system, when payers pay billed charges, they pay according to a rate schedule, called a charge master, established by the provider. To a many extent, this reimbursement system places payers at the mercy of providers, especially in markets where competition is limited. In the very early days of health insurance, all payers reimbursed providers on the basis of charges. At prssent the trend is shifting toward other, less generous reimbursement methods, and the only payers expected to pay the full amount of charges are self-pay (private-pay)

6. A fee schedule is a complete listing of fees that is used by Medicare to pay the doctors and or other providers, and suppliers. This listing of fee maximums is used to reimburse a doctor or other provider on a fee-for-service basis. Centers for Medicare and Medicaid Services developed fee schedules for physicians, clinical laboratory services, and durable medical equipment, as well as many other things. The Physician Fee Schedule pays for certain services that are provided by physicians and other healthcare professionals in all areas of service. These services include surgial proceduresm diagnostic tests, certain preventive services, and office visits. Payments are based upon the relative resources typically used to provide the service.

After a patient is treated by a doctor, medical billers calculate the bill for services, including any procedures performed by a doctor and any diagnosis during the visit. They prepare invoices for patients and insurance companies. Medical billers receive fee information from federally-based health programs and health insurers to determine the charges for treatments. Most medical billing professionals use medical software programs to calculate charges and print bills.

The amount of revenues from health insurance premiums that is spent to pay for the medical services covered by the plan. It demands nonprice controls on utilization, such as gatekeeping and concurrent review

For Medicare patients, about 42 percent of the typical hospital’s volume of patients, the U.S. Congress sets hospital payment rates. For Medicaid patients, about 16 percent of the typical hospital’s volume of patients, state governments set hospital payment rates. Private insurance companies negotiate payment rates with hospitals. Privately insured patients make up 32 percent of the typical hospital’s volume of patients. Private insurance company payment rates vary widely (American Hospital Association,

Bundled Pricing: As quoted by Zezza, Guterman and Smith in 2012, “In this type of payment system, a single payment is made for an episode of care—a defined set of services delivered by designated providers in specified health care settings, usually delivered within a certain period of time, related to treating a patient’s medical condition or performing a major surgical procedure.” Encouraging the physicians, hospitals to work together and coordinate the care of patients, to decrease re-hospitalizations, to improve the transition of care and to ensure proper care delivery after discharge is the ultimate goal of this payment plan (Zezza et. al., 2012).