The Reimbursement Of Medical Services Essay

It is essential for an administrator to understand how private and government payers impact actual reimbursement. Government payers have a standardized benefit structure. The one benefit is that registration staff have an easier time calculating payment due (copayments) for service and can set up payment arrangements. Since the most significant proportion of funds coming into a healthcare organization is usually payments from third-party payers, therefore, it is critical to know how each reimbursement affect the others that come in. Healthcare organization may have hundreds of different payer’s relationships in the form of different contracts that have their own rates of payment that are usually different from other payers for an identical

It is believed that NPs can overcome challenges with billing and coding, as well as Medicaid and Medicare, third party payers, commercial managed care companies’ reimbursements through appropriate coaching and remaining up to date on regulations. As mentioned earlier, implementing compliant electronic systems, staying well-informed of billing regulations, evaluating weekly reports, and consulting with compliance experts can aid in accurate reimbursement for NPs in primary care.

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.

Unit 2 AssignmentKelley WhitcombKaplan UniversityHI215-01: Reimbursement MethodologiesProfessor Kathleen SobelJuly 20, 2015Medicaid is one of the biggest insurance plans you can get in any state. In the state of Indiana, it is based off of your income. There is a certain amount (income) you have to make to determine if you will receive Medicaid or Healthy Indiana Plan (HIP). HIP is still a form of Medicaid, but you would have to pay monthly cost for it and have certain set of co-pays for certain services that is needed. HIP Plus is the recommended plan for members as it provides health coverage for a low, predictable monthly cost. HIP Plus also covers dental and vision services. If you do not pay your monthly payment you can be removed from

The reimbursement method used at St. Anthony’s hospital is quite distinct depending on the party doing the payments. Payments are received from Medicare, Medicaid, private insurers and also directly from patients. The party responsible for Medicare payment is the Federal government and it offers payment mainly for the elderly. With the Medicare payment, hospitals receive a flat fee depending on the case. According to Gee (2006), most hospital revenue has declined because of the revised payment set by the Diagnosis-Related Groupings. The fee for most cases varies according to the Diagnosis-Related Group (DRG) it can be classified under. For example, Medicare pays only a fixed amount for an elderly patient suffering from pneumonia regardless

Discuss the general differences between facility and non-facility rates. Discuss the MS-DRG system for hospital inpatient services. Include in your discussion the history of the MS-DRG system and the need for the updated system. There are two types of bills used in healthcare. Which type of bill is used for physician services? Which type of bill is used for hospital services? (Hint: your book is incorrect.)

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.

When it comes to the “incident of billing,” the Commission decided to consider that services rendered by clinicians who are not physicians but billed as “incident to” must be paid 100% of the physician fee schedule. The Commission stated that the incident care fee is predicated upon the care or service provided by the team, with the non-physician giving the direct patient care services and the physician taking responsibility to the overall welfare of the patient. They concluded that the team approach

Reimbursement for the advanced practice nurse (APN) is improving but how they fit into reimbursement systems is vey important. One question that arises is if the APN should be paid the same fee for service as a physician or should only a percentage of the payment be received. Most third-party reimburses, which include a few large insurance companies are now reimbursing APNs and more states are getting on board with reimbursements by developing reimbursement models for APNs (Hamric, 2009). For example, Aetna US Healthcare, Anthem Blue Cross and Blue Shield of Kentucky, Medicare and Medicate all credential NPs as primary care providers and pay at 85% of the physician rate. Tricare of Kentucky credentials NPs and pays 100%.

When working as a medical office administrator you will need to know how to complete the different procedures dealing with physician billing and reimbursement. Reimbursements involves more than what you just get paid, it’s a long and often convoluted process that start when you patients first contacts your office. In order to get the correct reimbursement it is important that you know the basics about reimbursements which includes the correct coding. The way to understand the aspects of the business is to know the basic of Medicare. Physician reimbursement is a three step process. The first step of the process would be having the appropriate coding number of the service provided by utilizing the current procedural terminology which is commonly

Healthcare reimbursement systems within the United States are a complex structure for obtaining payment for services rendered. The healthcare system officers are required to understand the ordinary principles of the payer system. Understanding the rules, and keeping up with the continuous changes will allow the providers, physicians, and facilities to gain an advantage in this growing healthcare domain. Both private and commercial insurance companies provide a diverse menu of choices to customers. All third-party payers create interest in decreasing healthcare costs and improve control access to the not needed services. This paper will address the complexity of the healthcare reimbursement systems in the United States. Additionally, the research

“Nurse practitioners were created in an environment of informal training, a lack of credentialing processes, increasing sophistication of medical care, and opposition” (Medscape). In 1970, Nurse practitioners stated that patients were pleased with their improved convenience of health care services. In the early 1980s, health care encountered challenges to clarify their scope of practice and nursing organizations offered titles and certifications to meet federal regulations for reimbursement (Medscape). Nurse practitioners faced several barriers to gain provider status and needed direct reimbursement to practice as independent health care providers. An aggressive campaign was created and nurse practitioners achieved legislation over 20 years, resulting in provider status in 1997.

The adult-gerontology acute care nurse practitioner (AGACNP) has many responsibilities. In addition to providing excellent patient care, the AGACNP must also know how to code for patient services, bill appropriately and know how much they should expect in reimbursement for specific treatments. Many legal issues arise for the AGACNP, including several forms of negligence; the AGACNP should be educated on the essential elements. Finally, the AGACNP must educate themselves and be prudent to avoid legal issues related to malpractice. In the following paragraphs, each of these issues will be discussed.

Government financed health care typically has more control to place limitations on care offered to patients and doctors in order to keep costs down. Since payers must try to deliver the most care for the

The realization of such services should be supported with adequate funding. Again, the stakeholders of the organization should be the major contributors towards the long term care service provision funding. The continuum care is crucial in the sense that it ensures that the care of the patients continues amid all the challenges and at all times. In case of financial challenges, the government ought to lend a helping hand to assist fund the important services (Pratt, 2010). Other private organizations with keen interest in healthcare provision