Molecular Reimbursement Rates

The Medicare Access and CHIP Reauthorization Act (MACRA) was passed in 2015 to support and change the way to pay and evaluated the healthcare in the United states (NHRI, 2017). This law mainly helps to pay the health care providers for the Medicare beneficiaries. Similarly, this law also provides the way of new funding for technical assistance, measure development, data sharing and establish a new federal advisory group that mainly help the healthcare providers for their health care service.

By evaluating the bill’s information, the case enters the MS-DRG category to determine the amount receivable by the hospital. The second step involves dividing the base payment into labor-related and nonlabor share. Mac adjusts the labor-related per an area's wage index applicable to a hospital's location (Reimbursement methodologies, 2016). However, adjustment of non-labor share for hospitals located in Hawaii or Alaska is per adjustment factor’s cost of living. In the third step, a hospital that serves a little portion of low-income patients receives a percentage add-on for every payment through PPS. The rate varies according to the low-income patients receiving the service, among other factors. Step four of IPPS involves offering a portion of add-on payment for every case payment through the PPS to approved teaching health facilities (Reimbursement methodologies, 2016). The last step analyses the costs sustained by hospitals to determine whether it qualifies for extra reimbursements. The aim of this extra payment is to protect a hospital from significant financial losses due to unusually expensive

There is a document for diagnostic laboratory testing that the centers for Medicare and Medicaid (CMS) policies with the respect to the circumstances under which laboratory tests are considered reasonable and necessary, and not screening for Medicare purposes is called National Coverage Determinations (NCDs). A Medicare assignment was accepted by Regional Pathology Services and is not allowed to bill Medicare beneficiary for the NCD tests listed below unless the ABN is executed by the provider that tells the beneficiary in advance of the service that they will be responsible for the payment of the test if the Medicare should deny payment.

Retrospective reimbursement method was based on actual cost the providers assumed the previous year. On this method rates were evaluated retrospectively and costs were used to determined the amount paid to the provider and had no incentive to control cost. On the other hand, prospective reimbursement methods can determine in advance how much a provider is going to get compensated. (Shi & Sing, 2017) The way retrospective reimbursement contain perverse financial incentives happened when institutions increased their profits by increasing costs and this system payment method was based on costs. Due to this issue the method was changed to the prospective to avoid abuse of the system.

Joint Commission International, Centers for Medicare and Medicaid Services (CMS), Lab is accredited by College of American Pathologist (CAP) (K.E., personal communication, 2016).

• A laboratory cannot bill a Medicare Beneficiary for a laboratory test unless it notifies the patient in writing that Medicare is not going to pay for the test

The Medicare beneficiaries’ contribution to the coverage gap decreases each year, with the majority of cost absorbed by the government and the drug manufacturers. Drug manufacturers also agreed to pay a fee to the federal government health care programs on branded prescription drugs (BPD), based on its sales of BPD’s. There was an expansion of the Public Health Service Act (PHSA), that required drug manufactures to provide eligible entities with significantly reduced drug price. The PHSA, also expanded those entities such as free-standing cancer centers and critical access hospitals (CAH), that were eligible to participate in the 340B program In, addition they also agreed to increase rebates on sales of prescription drugs to the Medicaid program (Spats, 2010). The rebate was increased from 15.1 percent to 23.1 percent. In addition, drugs, such as those used for pediatric care and clotting factor drugs there was a 17.1% rebate. Perhaps, most importantly, the firms extended the rebates to Medicaid patients enrolled in Managed Care Organizations (MCO). This new agreement allows plans to negotiate rebates in addition to the new ones

The College of American Pathologists or CAP is the accrediting organization for laboratory and testing personnel. CAP’s “accreditation process is so thorough, the Joint Commission [and CMS] accepts …their standards” in place of conducting their own survey of the hospital’s laboratory and personnel (Gartee, 2011, p. 47). This is because of the guidelines they follow to maintain their integrity and to remain the industry standard. In recent years, the “CAP [has] developed new check list” for continued improvements. Additionally, they are continuing to vet the requirements for the new next-generation sequencing or NGC-based test that is speeding laboratory procedures. So much so that the recent adoption of the new technology for clinical testing” was done prior to the new standards being approved (Aziz, et.al. 2015, p. 481).

It is important to follow payer guidelines when completing a claim form; otherwise, reimbursement will be delayed until the form is corrected.

For instance, patients will receive urgent hospital care and then will not be able to pay back their bills. Another policy affecting provider reimbursements is the change from volume-based care to value-based care. For instance, the Centers of Medicare and Medicaid (CMS) have mandatory reporting guidelines that all healthcare providers have to participate in. These reports were based off volume of care (fee-for service) for the past 9 years, but due to the high costs in healthcare, the CMS is changing over to a valued based care (pay-for

In the United States, health care has become a huge expense and has threatened the economy; additional measures need to be taken to address the rising cost of care. An individual spends an estimated eight thousand dollars a year in health care expenditures. Therefore, we need to recognize that how a physician reimbursement for payment has a vast impact on the economy and the rising cost of health care.

The United States health care system has can be assessed for quality measures in many different ways such as mortality rate or infant mortality, but the United States government often judges the efficiency of health care provider or network on the Centers for Medicare & Medicaid (CMS) core measures. The reason the United States gauge health care performance on CMS standards is due to CMS is the federal governing body that operates Medicare and how the hospital will be reimbursed from Medicare patients. Formerly Medicare would reimburse a hospital based all services the hospital provided a patient or fee for service (FFS). The rising

Between 2001 and 2011, the average patient’s out-of-pocket (OOP) cost for brand-name prescriptions rose by more than 80% (Tungol, et al., 2012, p. 691). The increasing OOP costs have contributed to a decrease

Anyone who has purchased prescription medications has probably wondered why they cost so much, and rightfully so. Medication prices in the United States have been on a steady increase for decades, however, prices have been drastically increasing as of recent. Pharmaceutical companies have tried to justify these price increases due to the demand, the high cost of research, and the high costs of development and approval. Notwithstanding, the extent to which the prices have increased is not justifiable. Americans should be against these high medication prices and take action because pharmaceutical companies are taking advantage of our healthcare system in order to capitalize from the sick. In order shed some light on this issue, the magnitude, scope, and consequences of these prices must be examined.

Mr. Rochelle agreed that extending tests to a broader patient pool with indeed spur growth, "the jump from high-risk to average-risk represents massive opportunity. Meaning, where high-risk might be 50% to 60% penetrated, average-risk is probably less than 10%, and it’s five or six times bigger than high risk." Moreover, recently the American College of Medical Genetic and Genomics published a position statement advocating that all pregnant patients should be offered NIPT. Price is another determinant of NIPT adoption. The average cost of NIPT is between $800 and $3,000, which makes it out of reach for many patients; however the large amount of competition in the space will surely bring prices down, and make NIPT affordable for a greater number of