Medicare Reimbursement Model Pros And Cons

Since the late 1980s, Medicare has reimbursed physician services using the Medicare Physician Fee Schedule (MPFS), which encompasses 10,000 procedure codes. Each code is assigned resource-based relative value units (RVUs), which are designed to reflect physician work, practice expense, and malpractice expense. To adjust for local differences in cost of living, each RVU is modified using geographic practice cost indexes (GPCIs) and then converted to dollars using a “conversion factor.” This system rewards physicians who produce a high volume of services; not surprisingly, Medicare Part B expenditures have grown rapidly.

Obtaining reimbursement for services provided is a necessity for the survival of many health care organizations. This paper will explain, in my opinion, why the Centers for Medicare and Medicaid Services (CMS) are involved in this development and how it affects the American public. I will offer a suggestion to ensure meeting policy and procedure. I will finish by discussing three ideas listed on the CMS website.

In order to more fully delve into this issue, this literature review will be focusing on three main areas of study as it applies to the topic of Medicare/Medicaid reimbursement and its relation to the Affordable Care Act. These areas of focus will include

In the past several years, there have been several changes in economic policy at federal and state levels. The two economic policies that present to be the most precedent for healthcare leaders with concern to facility reimbursement are the Affordable Care Act (ACA) and the switch from volume to value reimbursement. First, there is the ACA policy, which have affected healthcare facilities and their reimbursement methods. In fact, ever since this policy was implemented, provider reimbursement has started to decrease in terms of fee-for-service payments (The Common-Wealth Fund, 2015). In other words, the intention of this policy was to provide budget relief to the government payers as well as giving providers an incentive to provider patients with great quality of care.

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

Monitoring involves ongoing evaluation as a part of daily operations, while audits involve a formal process, where compliance officers benchmark staff

Through the history of health care, the standard of care changed from protecting our patient from injury and illness to a systemic entity to make money for insurance companies. Access to services and clinical outcomes are dependent on what health insurance providers will “pay” for in a clinical or community setting; as a result, patient safety, care and satisfaction has been negatively impacted.

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,

Compliance 360 has identified a number of areas which it can augment healthcare organizations to improve the audit process for Joint Commission audits. The program intuitively links contractors to regulations as evidence of compliance and monitors risk trends to

In today’s seemingly ever-changing world of healthcare regulation, medical professionals are burdened with many compliance requirements. On October 14, 2016, the Department of Health and Human Services released its final rule implementing the Quality Payment Program as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Starting January 1, 2017, clinicians who are reimbursed by the Centers for Medicare and Medicaid Services(CMS) are required to participate in the Quality Payment Program (QPP). (Centers for Medicare & Medicaid Services, 2016) The QPP replaced the Sustainable Growth Rate formula with the new payment structure in which clinicians are rewarded for delivering high quality care. There are now two pathways for

Most claims today are submitted through an electronic format directly or indirectly through a “clearinghouse” where claims are grouped and sent to the payer. Two primary payment grouping algorithms are DRG’s and APCs, both are used by Medicare for hospital payment and many commercial payers. Providers and payers use claims editing software to detect possible errors in claim submission to assure maximum payment for medical services and to shorten an amount of time from claim submission to payment. CMS has developed the National Correct Coding Initiative (NCCI) to promote national correcting coding methodologies and to control improper coding leading to inappropriate payment (Cleverley 26). CMS also has designated edit checks called the outpatient code edits (OCE). The OCE uses claim-level and line item-level information in the editing process. Each category in the OCE has six dispositions which help to ensure all Fiscal Intermediary/Medicare Administrative Contractor (FI/MACs). The four claim-level is rejection, denial, return to provider, and suspension; and the two-line item-level is rejection and

“Our founders got it right when they wrote in the Declaration of Independence that our rights come from nature and nature’s GOD, not from government.” says Paul Ryan, who at the time was running for Vice President of the United States with Mitt Romney in 2012. Paul Davis Ryan Jr, who currently serves as the 54th Speaker or Representative and also represents Wisconsin’s First Congressional District, has had many plans and accomplishments since winning his first election to the house in 1998. In this paper I will be discussing Paul Ryan 's plans for the future of health insurance, his work with current President Donald Trump and his accomplishments during his terms. I will also be talking about my opinion for Ryan’s future plans for America.

As you mentioned, the ACA has changed the way hospitals receive reimbursements from volume to valued-based incentive system. I learned that a percentage of Medicare reimbursement will be withheld unless hospitals meet benchmark performance measures in outcomes and patient satisfaction. Healthcare analysts are emphasizing that for hospitals to achieve the quality outcomes, a focus on assuring reliable measures, use of evidence-based practice, and skill in care coordination is needed (Jeffers & Astroth, 2013). A shift in the system will require care providers to have a patient-centered focus and experience in team care delivery. Jeffers and Astroth (2013) believe that graduate preparation and an advanced nursing degree are needed to prepare

The United States healthcare system has been the topic of much debate lately, with many propositions and reforms introduced to the public to remedy the many complaints made against the current system. The U.S. spend entirely too much money on health care. Based on data released by the World Health Organization (WHO), the "U.S. spent more on health care per capita ($4, 849) and more than 17 percent of its gross domestic product (GDP) to health care" (Squires, 2012).