Medicaid Reimbursement: A Case Study

In the state of Texas Medicaid is funded by state and federal programs. Those eligible to receive Medicare benefit is the low income individuals, families, children, pregnant women, elderly and individuals who suffer with disabilities (Hegar). The Texas Health and Human Service commission (HHSC) distributes the Medicaid (Hegar). Those receiving Medicaid benefits in the fiscal year of 2010 were found to be 55 percent female and 77 percent under the age of 21 (Hegar). Children accounted for 66 percent of all Texas Medicaid recipients in that year; however, 32 percent of those children actually received health care (Hegar).

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 United States (US) is distinguished for its medical advances, leading technology and astonishing discoveries in various science fields. These advancements in the health care ground have impacted and improved the health care delivery of several in the nation. The US is found among the wealthiest, most developed countries around the world; however, it is the only developed country that fails to provide universal health care to its people. Health care in the US is described as fragmented, inaccessible, and expensive. Diebel (2015) compared the health system in the US to other nations and supported that it is extremely overpriced, yet the end result does not always support its cost. Lack of coverage, high copayments plus deductibles force Americans to postpone seeking medical attention resulting in undiagnosed health conditions and complications of current diseases. In 2010, under President Obama’s mandate, Americans witnessed the birth of a controversial legislation, The Patient Protection and Affordable Care Act (PPACA). The goal of the PPACA is to improve just about every aspect of the system such the health of Americans, health care access and quality, while reversing the health care expenditure (Hahn and Sheingold, 2014). The aim of this paper is to discuss the PPACA and the Medicaid Expansion under the PPACA including its risks and benefits; as well as, the impact of the expansion in the healthcare delivery

Following the death of a Medicaid recipient, the program not only can but must attempt to recover costs from the estate of the deceased. Medicaid's official site says:

The Affordable Care Act (ACA) was signed on March 23, 2010 by President Barack Obama. The enactment of the ACA accounted for medical reform throughout the United States (Osmonbekov, Yordy, & Gregory, 2014). The provisions of document were all geared towards enhancing healthcare by lowering the costs, creating new consumer protections as well as improving access to care. Some of the provisions include section 2706 which establishes nondiscrimination in healthcare. Further, section 4001 provides national prevention, public health council, health promotion as well as an advisory group on prevention and integrative medical issues. The above provisions affect acupuncture practitioners in various ways.

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

The Affordable Care Act (ACA) highlighted the importance Medicaid played in insuring every American receive healthcare coverage. (42 U.S.C., 2010) Medicaid provides health benefits to over 71 million across the country. While involvement is optional, all 50 states participate in the program and requirements differ across the nation. The flexibility given to each state has allowed them to make their own decisions to work towards improvements that they believe would best benefit their region (Feldstein, 2015, p. 125-126).

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,

As Congress considers potential options to reform Medicaid, it is important to keep in mind patient access to prescription drugs and other healthcare services. Retail community pharmacies believe that Medicaid prescription drug benefit reform efforts should be focused on maintaining a Medicaid prescription drug benefit, maintaining patient access to adequate provider networks, fair and appropriate cost-based provider payments, and facilitating patient access to pharmacist-provided health care services.

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

Bill Haslam, the Tennessee state governor, announced that the state of Tennessee would accept the Medicaid expansion offer. The Medicaid expansion expands Medicaid eligibility to the region’s underserved populations living near or below the poverty line. The Medicaid expansion offer looked to be a major win for the state; however, others disagreed with this idea. Some of Tennessee’s lawmakers decided to deny the federal government’s Medicaid offer, even though many others wanted the offer to be accepted. The deal’s breakdown might be the result of “squabbling along party lines” which is a common theme at all levels of government. Although the deal was denied, it is still possible that the bill could still be passed with the help of the governor. The likelihood of Tennessee reviving its Medicaid expansion is a difficult one considering the state would have to fight. The Medicaid expansion could offer the state low-income citizens medical insurance, the state would come out of the deal with a net financial gain, and the state hospitals would come out on top.

Medicaid expansion is seen as a huge problem in this case it takes place among the 50 states. The environment includes the 50 states such as California, Texas, New York and New Jersey. Medicaid expansion offers financial protection. It also addresses the uncompensated care problem which involves paying and reimbursement for service rendered. Medicaid expansion also provides customers access to affordable coverage, as well as customers taking up that cover, which is a moral duty of the government. Medicaid also supports politically powerful interest groups who support expansion. The expansion of Medicaid helps rural hospitals stay afloat in states like Colorado, which added 400,000 people to the health insurance program under

Per our conversation: When the provider bills an amount, we don’t always pay that billed charges. Providers tend not to change the amount they are bill with different insurances. Amerigroup pays 100% of the Medicaid Fee Schedule. The claims that your referencing below paid code 20160RT at $66.09 per the Medicaid Fee Schedule. However, code J7324 denied for authorization. I understand that authorization was waived for April, I will have this claims reprocessed. Once the auth. wavier is put in place, code J7324 pays $223.39 of the Medicaid Fee Schedule. This bring the amount of the claim to $289.48 of the $473.00 the provider is billing.

Immigrants that work should be allowed medical coverage when they are working for American agriculture or any American employment. They are all pulling their hours and time to boosting the American economy; therefore, it is only logical for them to have private coverage. I don’t agree that they should receive state Medicaid coverage and should be left for Americans. Medicaid should not available for them until they have been in the use over ten years.

This grant is used for a variety of medical-related necessities. (1) Medical Services rendered in the course of hospitalization of any eligible veteran, (2) established rate of travel, currently 11 cents per mile, (3) payment for specialized modes of transportation, such as by ambulance, any veteran with a disability; (4) mental health services, consultations, professional counseling, and training of eligible veteran. Outpatient medical services includes examination, treatment, home health services, podiatric, optometric, dental, supportive medical services, and surgical services are provided to veterans in VA facilities or under fee basis hometown care programs. Sexual trauma counseling may be provided to a woman veteran which resulted from a physical assault of sexual nature, battery of a sexual nature, or sexual harassment which occurred while serving on active duty. Our agency will use this grant to provide medical services to those who are residing in the facility.