Hospital Reimbursement Analysis

There are several different things the health information manager can do to help with reimbursement. Ensuring that the proper codes have been assigned and that there is adequate documentation. The health information management department staff may also analyze case mix, manage on going

In the healthcare environment, the challenges that providers face are revenue shortfalls due to insufficient payments from the reduction of Medicare reimbursement rates (Shi and Singh, 2015. p238). Payers that have employment-based insurance are charged extra to cover the remaining balance. This process is called cost shifting. In some healthcare systems, the relationship between reimbursement reduction and cost shifting is correlated in an inversely proportional trend. As the decrease in reimbursement from public insurance such as Medicare and Medicaid, the method of cost shifting would increase.

It is essential for an administrator to understand how private and government payers impact actual reimbursement. Government payers have a standardized benefit structure. The one benefit is that registration staff have an easier time calculating payment due (copayments) for service and can set up payment arrangements. Since the most significant proportion of funds coming into a healthcare organization is usually payments from third-party payers, therefore, it is critical to know how each reimbursement affect the others that come in. Healthcare organization may have hundreds of different payer’s relationships in the form of different contracts that have their own rates of payment that are usually different from other payers for an identical

In my role with Liberty Mutual, I drove adoption of Medicare reimbursement models through public affairs involvement with multiple state workers' compensation committees seeking to update their reimbursement schedules in response to the implementation of ICD-10 coding requirements in October of 2015. With the state workers’ compensation authorities seeking to adopt CMS reimbursement type models, my involvement was directed at securing the inclusion of specific CMS rules governing correct coding and reimbursement practices including National Correct Coding Initiative Guidelines (NCCI), Medical Unlikely Edits (MUE), along with the Resource Based Relative Value System (RBRVS) for reimbursement rate setting.

HIM Personnel play an important role in the Medicare system. Medicare has transitioned from “fee for service” to providing incentive payments for providers that issue high quality care at affordable prices. In order to achieve the “pay-for-quality” incentives hospitals and health care officials must improve their documentation processes. “If it isn’t documented, it wasn’t done” is more important than ever. It is the responsibility of the HIM professional to ensure the integrity of the patient chart. HIM professionals monitor the quality of documentation and ensure all clinical documentation is complete and accurate. HIM professionals are the key to identifying process problems while keeping in mind patient safety, quality of care, and revenue integrity. Medicare requires that hospitals report quality improvement measures in order to receive payments; HIM professionals can directly impact Medicare incentive payments. HIM professionals are directly involved with the Medicare Audit Improvement Act. The HIM professional collects health data that is subject to the audits; HIM professionals are the point of contact for responding to Medicare audit requests.

Long-term care has many funding sources which includes government funding, privet insurance, out-of-pocket payments, and any combination of any of these programs. Privet insurance includes insurance for long-term care and managed care (HMO, PPO, POS). While government funding includes Supplemental security income, Department of veteran affairs, Older American act, Medicare, and Medicaid. With Medicare and Medicaid providing the most funding to long-term care (Pratt, 2016, p. 292-306). If Medicare and Medicaid are the biggest funders for long-term care what services do they cover, who do they cover, and what restrictions are put on the recipeits?

The value of CDI clinical documentation improvement (CDI) programs are important to any facility that recognizes the requirement of complete and accurate patient documentation. Documentation is very critical because it validates the care that was given. Furthermore, it shares important data to the caregiver and improve claims processing (Leventhal,2014). The three challenges are getting physicians to buy into the program, physicians are extremely busy so they are not connecting the dots on clinical documentation, and training the physicians to get them to understand they need to do better documenting (Leventhal,2014).

The reimbursement method used at St. Anthony’s hospital is quite distinct depending on the party doing the payments. Payments are received from Medicare, Medicaid, private insurers and also directly from patients. The party responsible for Medicare payment is the Federal government and it offers payment mainly for the elderly. With the Medicare payment, hospitals receive a flat fee depending on the case. According to Gee (2006), most hospital revenue has declined because of the revised payment set by the Diagnosis-Related Groupings. The fee for most cases varies according to the Diagnosis-Related Group (DRG) it can be classified under. For example, Medicare pays only a fixed amount for an elderly patient suffering from pneumonia regardless

Before the Obamacare, many individuals had no medical insurance. A noted author, Amy Anderson state: “Approximated 30 million Americans were anticipated to gain health insurance through the Affordable Care Act (ACA) or Obamacare; a comprehensive healthy workforce would be needed to meet the massive demand”. (Anderson, 2014)

The Affordable Care Act has drastically changed reimbursement (and subsequently patient care) for better and worse. While healthcare has become more accessible, quality of care and doctor-patient interaction has decreased. Statistically, hospitals have seen an improvement in compensation, but this doesn’t include private practice and outpatient centers. Government-run healthcare is slow healthcare, and to make up for this physicians have to work faster and longer. My mom’s work as a physical therapy assistant has her working 10-12 hour days in the off season months of summer, and my own work as a secretary at her office opened my eyes to the consolidation of providers to get better reimbursements, which leads to fewer private practices. While

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,

Most payers, commercial and governmental, will “generally deny reimbursement if medical records are not complete when a claim is processed for payment” (Delinquent Medical Records, n.d.). For this reason, a constant review of both delinquent and incomplete medical records is crucial to the success of a hospital. The delinquency of a medical record is concerned with the appropriate time frame that a physician must certify and complete the medical record, however a complete or incomplete medical record is directly related to the content of said medical record. To consider a medical record “complete”, one must review the standards for the content set forth in the Medical Staff Rules and Regulations. An incomplete medical record is missing required

It is nearly impossible to avoid clinical denials entirely. Therefore, the health information management (HIM) department should have strong procedures built as a defense against clinical denials. Ensuring the claim is sent to the payor appropriately is complicated since coders “must not only ensure they are within the parameters of official coding guidance, but also they must review the record to justify the clinical significance” (Brownfield et al., 2014). For example, universal coding guidelines in ICD-10-CM explain that coders should not assign codes for signs and symptoms with an established diagnosis if the signs and symptoms are integral to the established diagnosis. For example, if the patient is experiencing lower back pain and the

NH DHHS has been in contact with the New Hampshire Hospital Association and New Hampshire hospitals to discuss the 2011 DSH audit results and outline a recoupment process for hospitals with excess payments. NH DHHS has been working to create a timeline for repayment that would satisfy CMS requirements yet be sensitive to the hardship that these repayments will impose on hospitals that are already strapped for cash. In total, $20,892,160 will need to be collected from hospitals that were deemed overpaid, with those funds eventually being redistributed to hospitals deemed underpaid per the 2011 DSH audits conducted by Myers and Stauffer. The final 2011 DSH audit reflects an overpayment to New London Hospital of $842,856.

Hosseinzadeh et al. In [17] this work analyzed predictability of hospital readmission without targeting any specific disease. In this analysis considered a dataset ,covers demographic, clinical procedure-related and diagnostic-related features along with drug information of patients predict the readmission within 30 days (short-term readmission prediction) above 65 years of age. Therefore, it’s contained comprehensive results of feature reduction methods and the performance of the prediction models is modest. Consequently, this studied did not consider cost analysis and grouped features importance mining and these studied not targets towards specific disease prefer like diabetes.