Medicare Referral System: A Case Study

Consequently, it become a financial problem where physician sees no improvement in their revenue/profit, and the cost of treatments continue to rise as reimbursement challenges the physician’s charges. There is always a cost to a better health care and coverage, and vast of it comes from taxation. Hospital and physicians function on funding to keep the door open and operating, and majority of the funding are from taxation. For

The health facility in this case study experienced several problems and issues beyond possible solution efforts by the time. One of the main problems is based on the perfect way of handling the various challenges attributed to a shift from the hospital’s fee-for-service in the case of managing care environment. Besides, some local physicians were loyal to Dr. William and had the necessary flexibility and availability to assist the doctor in various ways, but today they are no longer available to assist the doctor towards the achievement of his medical and societal mission. The physicians were always available and loyal to the doctor and they could volunteer their efforts especially in cases of physician shortages in the health center. The physicians cannot afford the time they once used for volunteering activities in the health facility to assist Dr. Williams (Swayne, 2008). The reason behind this problem is that the physicians have now been employed by various managed health care organizations. Others have been involved in various contractual agreements such that the partners prohibit them from working with the health care facility. Although the health care facility has a few small groups or individuals offering primary care, these individuals and small groups are still struggling to survive in the industry. As such, the majority of them cannot

Blake Memorial Hospital’s internal weaknesses include: poor quality of care, increasing operating debt and costs, poor location, a high percentage of Medicaid low-scale reimbursement, forceful physician demands, and potential physician defection. For example, most payments for the in-house services at Blake Memorial Hospital were not successfully collected. In addition, the income has remained fixed while the hospital expenses continued to increase. Moreover, the six off-site clinics are in bad condition and need to be rectified (Rakish et al., p. 136).

Medicare payments to hospitals grew annually by 19 percent; the Medicare hospital deductible had expanded, placing a burden on beneficiaries; the solvency of the Medicare Trust Fund was endangered by escalating costs; expenditures for hospital inpatient care jeopardized Medicare's ability to fund other necessary health programs; Medicare's payments for comparable services were vastly different across hospitals nationwide; and the cost-based system imposed burdensome reporting requirements.

In 1983, the Medicare prospective payment program was implemented which allowed hospitals to be reimbursed a set payment based on the patient’s diagnosis, or Diagnosis Related Groups (DRG), regardless of what treatment was provided or how long the patient was hospitalized (Jacob & Cherry, 2007). To keep the costs below the diagnosis related payment, hospitals had to manage efficiently the treatment provided to a client and reduce the client’s length of stay (Jacob & Cherry, 2007). Case management, or internal case management “within the walls” of the health care facilities was created to streamline costs while maintaining quality care (Jacob & Cherry, 2007).

The U.S government spends about 17% of GDP on healthcare industry which is enormously high as compared to any other industrialized nation. President Obama signed the comprehensive healthcare reform – Patient Protection and Affordable Care Act on March 23, 2010. The law worked on the principles of triple aim to reduce healthcare cost, improve quality and access for the U.S citizens. One of the fundamental component of Affordable Care Act that will affect the caregiving to the U.S citizens is payment cuts to the hospitals if they do not provide quality care to their patients. The reason behind these payment cuts is because Part A Medicare Trust may go bankrupt by 2017. Hence, it is necessary to bring the cost of healthcare under control along with providing quality care to the patients. In order to contain cost, ACA proposed Medicare Readmission Program. Effective October 1, 2012 Medicare will reduce payments to the hospitals that will have higher percentage than the specified amount of preventable readmission rates. Effective fiscal year 2015, Medicare will penalize the hospitals by 1 % that will show higher number of hospital acquired infections (KFF, 2013). CMS has reported that approximated one out of every 5 Medicare patients are admitted back to the hospital within 30 days of their prior inpatient stay. Readmission rates are generally high for hospital that serve more vulnerable population like safety net hospitals. The high readmissions are caused by a

Do you have some durable medical equipment, prosthetics, orthodics or associated supplies (DMEPOS) in your medical office supplied by a home medical equipment (HME) supplier? Such an arrangement is often called a loan or consignment closet.

Readiness, preferences for training, usability features, and expectation towards e-Rx were the crucial aspects to review in order to plan and initiate processes involved in implementing e-Rx at the VA. Currently, the VA is equipped with a strong team of PBM as well as ADPACs in each department to handle operational and technical issues related changes throughout the organization.

Discussion with a worker on the drive to meet a new referral. The worker explained that Susan (name change) had been referred to the family support team, as she had a notice to leave from her transitional property. A transitional property in a temporary housing option people can live in for a short period, while waiting for permanent housing with Department of Housing.

Since 2014, hospital chains and insurers have merged and acquired urgent-care centers with the express purpose of taking advantage of this new business venture. There are many reasons for this endeavor and one of them happens to be the rise in active patients aged 50 and over who opt for convenient care for illness and injuries at the same time appreciate being connected to a bigger system where their primary doctor may practice and where urgent visits can become part of their medical record.

An AEP treating Medicare patients have the choice to either bulk bill patients or set their own fee for service rates. If the AEP chooses to bulk bill, Medicare publishes claim slips that can be used for the bulk billing of patients. If a fee is set and a gap payment is required to be paid by the patient directly to the AEP, an invoice is required to be provided to a patient for the services with all specific information for clients to they can claim back the amount from Medicare. The invoice used by the patient to claim back the rebate amount from Medicare must include: Patient name and details including Medicare number; Partitioners name and either: address of the place of practice from which services was provided or provider number for

Two major issues that have an impact on all the officials are reimbursements and reduced patient population. Reimbursements will affect all the officials because payments for services rendered will be issued at a later date. Therefore, the

In summary, this research has the potential to improve the quality of life for Medicare beneficiaries through decreases of side effects, improved convenience, decreased time receiving treatment and reduction in economic hardship. Single-fraction treatments decrease cost to the patient and decrease the number of treatments and resources needed. In addition, Medicare providers will benefit through the education of effective treatment modalities for their metastatic bone cancer

The discipline referral process is related to Outcome 5 – Social, Political, and Legal Leadership in different ways. Firstly, there is a need to uphold state, federal and local laws as well as statutory requirements that support the well-being of children. The process of having a referral system puts in place a check and balance practice which prevents children from being unfairly treated. Children are affected by their environment and so this may cause them to act out. The referral system, therefore, encourages the act of not only treating children with respect but also encourages deeper examination to find out issues that are affecting them. If administration knows the issues that are affecting the children then solutions can also be found.

To learn and understand about the different health care delivery systems around the world. My expectations are to learn about the advantages and disadvantages of the different health care delivery systems. I also expect to learn about the different actors that play a part in the delivery of health care, and how social determinants, economic and political factors, as well as concepts like cultural competency play a role in the different health care delivery systems.