Healthcare Reimbursement System

With the growing telemedicine trend there is an increased focus on how to reimburse for these types of patient services, which differ from state to state due to each state 's varying laws, regulations and policies. 2 The current healthcare payment structure in the United States is fee-for-service which makes it imperative for healthcare professionals to use correct codes for proper reimbursements with Medicaid, Medicare and private insurance providers.

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,

Review of the literature identifies the issue of fair pay for similar work has been an issue for some time. According to Grey (2013, par. 7) the pay parity for NP and PA became an issue when two insurance carriers dropped reimbursing rates for NP and PA by 50%. On March 1. 2013 NP and Physician Assistants (PA) who run private practices reported they were struggling to maintain their business because of the lower rates paid by insurers (Grey, 2013, par. 8). Mccarger (2017, p. 15) discusses how payment parity is strongly opposed by medicine, and is primarily historical in nature. Advanced practice nurses still need to justify their value in a historically hierarchical framework of health care where the physician is the chief authority

Based on the political and economic environments of states and the federal government the methods of health care reimbursement have been required to evolve. With the introduction of the Patient Protection and Affordable Care Act (PPACA) new laws have been set into place that has caused a stringent review of spending on health care. All care provided is being examined for effectiveness, quality, and the actual need of the service. Unnecessary health care functions are being screened and eliminated. The government and other insurance providers have begun to place cost containment measures in place only paying for those procedures that are deemed medically necessary for the illness that the patient is currently afflicted with. This has a direct impact on the monies that the government and insurance providers will reimburse for services. The following paper will look at the major types of reimbursement activates currently in place. The writer of this paper will also speculate on the future of health care reimbursement and how it will affect his current organization.

The United States health care system has can be assessed for quality measures in many different ways such as mortality rate or infant mortality, but the United States government often judges the efficiency of health care provider or network on the Centers for Medicare & Medicaid (CMS) core measures. The reason the United States gauge health care performance on CMS standards is due to CMS is the federal governing body that operates Medicare and how the hospital will be reimbursed from Medicare patients. Formerly Medicare would reimburse a hospital based all services the hospital provided a patient or fee for service (FFS). The rising

The government influences the delivery of healthcare by setting forth several different requirements. As with any state or federal agency, licensure of both the facility and providers are required (Gartee, 2011). In addition, there are certain standards that must be met by the facility in order to participate in government funded programs. The most widely known programs within the healthcare industry are Medicare and Medicaid.

The outcome is that many low-income adults and other Medicaid beneficiaries continue to suffer from pain and discomfort of tooth decay and gum disease. Eventually, at some point, patient may need to go to expensive emergency rooms, where they can do little but provide temporary pain relief. Consequently, untreated oral diseases can increase anxiety and may worsen other health problems, such as heart disease, diabetes and rheumatoid arthritis (Choi, 2011).

To descripe the reimbursement model for todays US healthcare market is to say it is fragmented and complicated. The government accounts for 64% of the US healthcare market, followed by private insurance companies, and self-pay (Self-funded plans, or cash). This fragmentation causes a lot of confusion, as each plan can have many different payment systems within itself.

Hospital reimbursement begins with the Clinician’s documentation most especially the Physicians who must ensure a complete, precise and accurate clinical documentation to support reimbursement and optimal quality reporting. It is of paramount importance that the Physicians ensure the documentation in the medical records reflects the genuine and exact story of the patient (Corsello, 2015). Additionally, if a Physician's documentation such as the primary diagnosis does not clinically reflect the documentation recorded in the patient's chart, there is a potential that the insurance company or the Centers for Medicaid and Medicare may deny the hospital reimbursement for the services provided to patients. Furthermore,

You put together a good response to this week's discussion question. You state that one of the biggest obstacles facing the long-term care system today is the reimbursement system. I agree. However, I think the sheer increase in the elderly population is a major problem for todays long-term care. The elderly population is expected to account for 21.7% of the us population (Department of Health and Human Services, 2016).

I have chosen the Inpatient payment structure as my topic because it is an area of healthcare that few people understand. Hospitals and physicians alike must adhere to strict guidelines set forth by governing agencies; however, these guidelines are constantly change, forcing hospitals to adjust operational costs in order to maintain overall revenue from those governing agencies. Those agencies continue to cut costs which thus cuts revenue to hospitals which ultimately leads to a decrease in hospital growth (White & Wu, 2014). The complexities the healthcare payment structure offer me a continual learning experience and challenges my critical thinking skills. Also, understanding payment structure

Fee for service is a common healthcare reimbursement method performed among physicians in the United States. In short, fee for service is where a provider is reimbursed for each procedure or service performed by a set reimbursement rate. For example, a physician can perform an office visit, administer a vaccine, can draw and test 3 different labs and they will receive a separate reimbursement for each of these services. “Sometimes, there is little relationship between the actual cost to provide a service and it charge” (Casto & Forrestal, 2013, pp.7). A disadvantage for the patients with a fee for service method according to (Casto & Forrestal, 2013) is that they may have a higher deductible and co-insurance to pay, this is probably

The direct reimbursement plan is a popular plan among sales representatives. This plan allows more flexibility with potential customers and gives the sales representative more room to get to know the customer without having to worry about using money of their own to pay for dinners, hotels and transportation issues (Johnston& Marshall, 2010). This type of reimbursement plan encourages more sales and helps the sales representative to effectively plan a way to secure a final sale with the customer. The limited reimbursement plan sets expense limits on sales representatives with potential customers (Johnston & Marshall, 2010). These types of limitations can often hinder the employee from taking further steps in trying to secure a sale. When a

When we received the insurance reimbursement, we always deposit the check to revenue account. We never deposit the check to the expense account. Maria deposit the check into the correct account. If there is any expenditure on vehicle repair, please let me know. I will do the budget amendment to offset the repair

Changing reimbursement models also haunt health care officials (Healthcare Financial Management Association, 2014). Recent years have witnessed a progressive