Hospital Rate Regulation Act Case Study

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 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,

For example, Medicare established programs that link quality of service to payment amounts. One program is called the Hospital Readmissions Reduction program (Medicare.gov, n.d.). This programs seeks to reduce readmission rates in hospitals (Tepper & Wojciechowski, 2013). Hospitals that experience high rates of readmissions and that participate in CMS’s Inpatient Payment System (IPPS) are subject to a reduction in payment from CMS (Medicare.gov, n.d.). This type of pay for performance creates unintended

Revenue determination is an important tool for health care organizations because it allows for efficient management of payment systems. This paper will look at the different components that form the payment-determination bases of revenue determination. Moreover, the difference between specific and bundled service payments will be discussed. Lastly, the three ways health care providers control their revenue function will be highlighted.

Hospitals should be encouraged to participate because improving hospital care is likely to be essential to success (McClellan et al, 2010). Accountable care organizations can be implemented through different payment models. These could include opportunities to share in demonstrated savings within a fee-for-service environment, in which providers took on no new financial risk. They could also include limited or substantial capitation arrangements, in which payments were unrelated to the volume of services provided, to the intensity of service use, or to the frequency of face-to-face meetings, and in which providers took on some financial risk for poor-quality results or failure to control costs (McClellan et al,

As stated above, 11.4% of the population is still uninsured or under-insured. Of these patients, 40% have outstanding medical bills that will most likely go unpaid to the providers (3). This equated to $74.9 billion in 2013 of total uncompensated care across hospital systems and community providers (4). Not surprisingly, hospitals took the brunt of this cost at 60%, equaling $45 billion in uncompensated care. This raises the question of whether providers or other organizations can supplement the already subsidized monthly premiums. In theory, this model would be a win-win for the patient and provider, such that the patient stays covered and the provider is reimbursed for their

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

Hospitals were previously reimbursed by Medicare by fee-for-service. The fee-for-service plan paid for each service or treatment the hospital provided. As you can imagine this led to hospitals providing unnecessary treatments for financial gain. After 1983 Medicare started reimbursing hospitals based on the prospective payment system. Payments for services or treatments are based on preset payment amounts. The payments were based on diagnosis-related groups (DRG). This means hospitals are paid based on diagnosis and payment includes all hospital resources to treat the condition. By changing the reimbursement method, Medicare can contain cost. In 1992 a new reimbursement method for doctors was established. This payment method is called Resource Based Relative Value Scale (RBRVS). This approach contains cost by paying the same fee for the same service. Payments are determined by 3 components physician work, practice expense, and professional liability insurance. Payments are calculated by multiplying the combined costs of a service by a conversion factor determined by Medicare and adjusting for geographical differences in resource costs. By using these payment methods, Medicare can simplify the payment processing contain cost and encourage improvement of

The external stakeholders are the community, patients, MedKey System members, CMS, HMOs (ie. Blue Cross Blue Shield and Tri-Care), and any other private insurances (Richards & Slovensky, 2004). Medicare reimbursement in Alabama was the lowest rate in the nation. This was a constant struggle for the hospital administrators to try to operate on such low reimbursements for their services, which is a threat. Eighty percent of patients were Medicare or Blue Cross in which there was difficulty-negotiating prices with Blue Cross due to monopoly. Buyers have high bargaining power as reimbursements rates are low from Medicare and Blue Cross held monopoly in the services area so negotiating prices was difficult. Suppliers have lower bargaining power due to low Medicare reimbursements and difficulty negotiating prices with Blue

There are many healthcare payment methods used when processing claims billed by a hospital or provider for services rendered to the patient. Those payment methods include, fee for service, bundled payment, value base pay, capitation and global budget. As stated previously in this discussion, HF is the most prevalent reason for an increase of readmissions rates ranging at 40% (Hobbs, 2016). Subsequently this problem affects how reimbursement is made payable to the hospital or providers. Currently, HF is greater among patients who are MCR beneficiaries and readmission rates for this population range from 22% to 25% (Banoff, 2016). With the substantial increase of readmissions, attracted attention from the Centers for Medicare and Medicaid

We don’t have just a single body which takes charge of healthiness in this country. Both physicians as well as insurance firms get a ridiculous amount of incomes from consumers. The government control to some extend through the financing of Medicare and Medicaid but relies on the private sector for the provision of services (Shi, L., & Singh, 2010).All arguments on finding solutions to insurance problems enthuses unlimited urge. Problems like making health care facilities accessible, organizing coverage’s, and to rein in expenditure by federal, organizations, and individual entities repeatedly stands out.

In the last four decade, the cost of healthcare services has been on the rise, thereby leading to the promulgation of the Health Maintenance Organization Act of 1973 (Salmon, J. W. 1995). This act provided the opportunity to control healthcare cost, through membership of a provider network that

Imagine a time in the history of our nation where the hospitals within were the envy of the world. In the 1960’s the medical facilities in the United States employed more people than the auto industry that served a population where one out of eight would be admitted annually (Stevens, 1996). These marvelous facilities contained air condition, artificial lighting, electric beds, carpeted private rooms, sterile supply services, advanced laboratories, and pneumatic tube systems. The infrastructure was great and it supported a population where more than 70 percent had hospital insurance (Stevens, 1996). In addition to, medical insurance was gaining popularity and major medical insurance companies started to grow.

Since 1992, health cares like Medicare have reimbursed physicians on a fee-for-service basis that weighs their service and expenses and then converts the weights to money (Wilensky, 8). According to Gail Wilensky, “Congress replaced an existing spending constraint with the Sustainable Growth Rate (SGR) to reduce reimbursements if overall physician spending exceeded the growth in the economy” (Wilensky, 8). Physicians and PAs are having a hard time with health-care reimbursement. It is causing many problems and Congress needs to come up with a solution. ¨This article states several promising models, including patient-centered medical homes, accountable care organizations, and various payment bundling pilots, that could offer lessons for a larger reform

The first example of a cost containment option is provider payment reform. Therefore, the provider payment reform consists of changing provider payments from a fee-for-service system to a value-based payment system (Grinsburg, 2013). As a result, health care providers will be rewarded for increasing quality while reducing health care costs (Grinsburg, 2013). In addition, the new payment reform will reimburse health care providers for care coordination and patient education services that are not reimbursed under the current fee-for-service payment system (Ginsburg, 2013). Overall, value-based health care services tends