RBRVS: Is The Nationally Uniform Relative Value

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.

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.

The place of service can greatly affect reimbursement, depending on the type of service provided and the location. The reason being is that Medicare typically reimburses physicians based on a method called Relative Value Units (RVUs), which has three components: work,

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

There is a growing trend in the United States called pay-for-performance. Pay-for-performance is a system that is used where providers are compensated by payers for meeting certain pre-established measures for quality and efficiency (What is Pay-for-Performance, n.a.). We are going to be discussing what pay-for-performance is. There are different aspects of pay-for-performance which include; the effects of reimbursement by this approach, the impact cost reductions has on quality and efficiency of health care, the affects to the providers and patients, and the effects on the future of health care.

In an office setting, RBRVS determines overall cost of visit. The Relative Value Unit (RVU) is a created value to measure resource consumption by assigning numeric values. RVUs are divided into three domains, each with different weight. This metric sums the salary of provider, facility/practice expense (inclusive of utilized resources), and malpractice adjustment (exposure level to account for). This determines the overall Relative Value Unit (RVU) which is then multiplied by the GPCI (geographic index specific for each factor) which adjusts for cost differences in different areas. The total RVU is multiplied by conversion factor to equal reimbursement. Doctors working more and producing more RVUs are making more

Besides, the financial incentives for hospitals and physicians that belong to ACOs, Jaffery & Golden 2013, asked and then answered the question “why would providers join this program? One reason is to prepare for the future”. Fee-for-service reimbursement, which has been how hospitals get paid for their services rely solely on the volume of patient seen without taking into consideration the quality of care provided. Payers today, such as government, commercial insurers, employers, and individual consumers are now requesting on value -based-payment, which consist of delivering the highest level of care at a lower cost. The volume based system even though the traditional way of how payments are made is not a viable long-term option (Jaffery and Golden, 2013, p.98).

This would support the claim that during this time an abundant amount of work was needed to adequately protect and care for others. Documents 1, 2, 7, and 8 all tell of the additional work that was needed to provide sufficient care for the patients.

In an ever increasingly competitive healthcare environment, there is a need to determine that 1) the desired outcome is produced, 2) quality care is provided and 3) the cost of care is the lowest possible. Yet the basis for the determination of such is having the right kind of measures available. Dr. Trudy Mallinson is one such specialist in the program who has the year of experience

Research for this capstone project is designed to determine the preferred model of provider construction to meet the unique staffing needs for the MidMichigan Health System (MMHS) consistent with the existing staffing model. Hospitals face a number of challenges making it difficult to improve patient care and reduce costs. One way healthcare organizations can effectively address many common concerns is by developing and deploying an appropriate provider staffing model. The ultimate goal of MMHS is to provide quality care for patients while complying with the standards set forth by the Joint Commission accreditation and reducing 30 Day

3. Evidences say that physicians who are paid under FFS happen to treat patients with excess services and procedures than those who who are paid by other methods like capitation (Gosden, Forland, Kristiansen, et al., 2000). (Gosden T, Forland F, Kristiansen IS, et al. (2000). "Capitation, salary, fee-for-service and mixed

The predominant system of payment to healthcare service providers had been the fee-for-service system for years. This system rewarded the providers for the intensity of their work. However, greater volume of services was not necessarily associated with better service quality. This incentive structure had policy makers concerned and thus, came the pay-for-performance into being established to improve service quality. The use of this system has been expanded by the Patient Protection and Affordable Care Act (PPACA). Many studies were performed to identify ways to make the system more effective. However, the studies had somewhat mixed results.

However, a numerous methods have also been standing for some time now trying to be the best health care system. While doctors discuss the value, time, work, and implications of a perfect system, it all comes down to money whether it is seen in a negative or positive way (Sweetland, 2013). A salary is where a lump sum payment is made to the clinician for a set number of working hours or sessions per week. Capitation refers to when a payment is made to a clinician for every patient for whom they provide care (Gosden et al., 2010). With new concerns over the effects of the Affordable Care Act (ACA) on access to care and continued frustration with third-party reimbursement, models such as direct primary care provide a satisfying alternative for both doctors and patients. With some specific policy changes at the state and federal levels, this innovative approach to primary care services could restore and revolutionize the doctor–patient relationship while improving the quality of care for patients and saving many practices all at once (Romano & Benko, 2001). With a solid base of patients the clinic will remain open thus allowing me the opportunity to have a job in my

Since the advent of value-based (VB) care and reimbursement models, more and more physicians are being held accountable for the value of the services they provide and being paid for that value instead of for the services themselves. The big question of course is, how will meaningful use affect the Revenue Cycle Management systems and operational processes that have been in place and supporting a fee-for-service structure for decades?

Relative value units (RVU) Our text states “ The essence of an RVU is that costs associated with providing services are compiled for all services, and costs for each service are measured against the average” (Smith, 2014). This is a formula that has taken the place of the former customary and reasonable payment ability under the Omnibus Budget Reconciliation Act of 1989. This has implemented a payment fee for physician services in patient care. This fee incorporated payments for such factors as physician time, office costs, and malpractice costs for services provided by physicians.