What Are Examples Of Non Reimbursement Conditions

In my role with Liberty Mutual, I drove adoption of Medicare reimbursement models through public affairs involvement with multiple state workers' compensation committees seeking to update their reimbursement schedules in response to the implementation of ICD-10 coding requirements in October of 2015. With the state workers’ compensation authorities seeking to adopt CMS reimbursement type models, my involvement was directed at securing the inclusion of specific CMS rules governing correct coding and reimbursement practices including National Correct Coding Initiative Guidelines (NCCI), Medical Unlikely Edits (MUE), along with the Resource Based Relative Value System (RBRVS) for reimbursement rate setting.

Melnick, G., & Fonkycj, K. (2013). Fair pricing law prompts most California hospitals to adopt policies to protect uninsured patients from high charges. Health Affairs, 32(6), 1101-1108. Retrieved from http://ezproxy.nu.edu/login?url=http://search.proquest.com/docview/1372932073?accountid=2532

“Starting in 2009, Medicare, the US government 's health insurance program for elderly and disabled Americans, will not cover the costs of "preventable" conditions, mistakes and infections resulting from a hospital stay. So for instance, if you are on Medicare and you pick up a hospital acquired infection while you are being treated for something that is covered by Medicare, the extra cost of treating the hospital acquired infection will no longer be paid for by Medicare. Instead, the bill will be picked up by the hospital itself since the rules don 't allow the hospital to charge it to you” (Paddock, 2007).

Healthcare in the U.S is most expensive than any other developed country. The U.S spends far more on per capita as compared to any other developed. U.S scores low on many outcome measures, inefficiencies and wastes and quality measures as compared to other countries. The Patient Protection and Affordable Care Act is developed to strengthen these failures in the health care system. The U.S healthcare is transforming care from volume based reimbursements to value based payments. The healthcare law works around providing more patient centered care and better preventive care. One of the payment reforms with Obamacare is to penalize the hospitals with high readmission rates for the three conditions – Acute Myocardial Infarction, Heart Failures and Pneumonia.

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.

“Establishing a written financial assistance and emergency medical care policies; limiting the amounts charged for emergency or other medically necessary care to individuals eligible for assistance under the hospital’s financial assistance policy; to make reasonable efforts to determine whether an individual is eligible for assistance under the hospital’s financial assistance policy before engage in extraordinary collection actions against the individual; and conduct a community health needs assessment (CHNA) and adopt an implementation strategy at least once every three years, which are effective for tax years beginning after March 23, 2012” (New Requirements for 501(c)(3) Hospitals Under the Affordable Care Act, 2010).

In October 1, 2008, the CMS adopted a non-reimbursement policy for certain "never events, which are defined as non-reimbursable serious hospital-acquired conditions (Sollecito & Johnson, 2013, p. 25). Examples of “never events” include surgery on the wrong body part; foreign body left in a patient after surgery; mismatched blood transfusion; major medication error; severe “pressure ulcer” acquired in the hospital; and preventable post-operative deaths (Center for Medicare & Medicaid Services, 2008)

In other words, ever since the Affordable Care Act was passed, millions of Americans have insurance. This can be worrisome to non-profit hospitals due to the large number of patients. For example, there are far more patients than there are physicians, which causes the quality of care for these patients to diminish. Physicians cannot keep up with the amount of patients they need to see as well as give every patient 100% of their attention it is simply impossible. Therefore, hospitals may start to implement a policy where only certain insurances can be seen at the hospitals, excluding emergency situations of course, while others have to either see there primary doctors or specialists. In other words, physicians are discharging patients too early, which cause a large amount of them to be readmission. Therefore, this is costing the hospital millions of dollars as well as affecting the patients’ overall health. If there was a stricter policy on who can and cannot go to the hospital than patients may start to receive better care and non-profit hospitals can focus on their main mission and that is to treat the people of the community with a high and effective quality of

Based on the political and economic environments of states and the federal government the methods of health care reimbursement have been required to evolve. With the introduction of the Patient Protection and Affordable Care Act (PPACA) new laws have been set into place that has caused a stringent review of spending on health care. All care provided is being examined for effectiveness, quality, and the actual need of the service. Unnecessary health care functions are being screened and eliminated. The government and other insurance providers have begun to place cost containment measures in place only paying for those procedures that are deemed medically necessary for the illness that the patient is currently afflicted with. This has a direct impact on the monies that the government and insurance providers will reimburse for services. The following paper will look at the major types of reimbursement activates currently in place. The writer of this paper will also speculate on the future of health care reimbursement and how it will affect his current organization.

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 proposal for bundled payments (CCJR) will force hospitals and other health care facilities to change and adapt. The proposal would include medical severity diagnostic-related groups which would help calculate targeted prices for each severity group and each hospital separately. Several controversial components would be included in the proposal. Mandatory participation is one of the key requirements to the proposal. Another controversial component to the CCJR program is that hospitals would be exclusively responsible for the bundled payment program and any financial excess. However, these controversial components are key features to ensuring the proposal’s success which will help patients and providers in the future. Another reason the CCJR proposal will force hospitals to adapt is that the hospitals would be financially accountable for the quality of care. If the hospitals fail to meet three specifically designed protocols for quality, the hospital(s) would be ineligible for savings

Medicare guidelines state that services are excluded from coverage when performed for a purpose other than treatment of a specific illness, symptom, complaint, or injury.

The conference offers workshops that will clarify changes in the new Medicare policies as well as provide information detailing the supplemental insurance policies available to patients. This training offers a wonderful benefit to North Shore because when all care coordinators are educated about the new Medicare policies and can calculate the correct supplemental insurance plans for each patient, coordinators can recover treatment costs for the clinic. While the total cost to attend this conference is $18,000, this amount pales in comparison to the treatment costs that will be recovered due to the education of the clinic’s patient coordinators. Knowledge of the Medicare changes can help coordinators recover, for the clinic, up to or exceeding $50,000, per patient, in some cases. Therefore this one time cost will reap large returns down the

The Centers for Medicare & Medicaid Services (CMS) was made headlines by releasing charge and Inpatient Prospective Payment System (IPPS) installment data at the MS-DRG level for hospitals across the country. In spite of the fact that this data has long been openly accessible, having it provided more easily available brought about it by being reported of various media outlets. Tragically, this information discharge was not accompanied by expert information clarifying what the numbers mean, creating an interest for hospital facilities to react, at the end of the day, to forceful request in regards to their charging practices.

In an effort to curb these costs, in 2013 the Center for Medicare and Medicaid Services (CMS) enacted the Hospital Readmissions Reduction Program. Under this program, hospitals are penalized for readmissions occurring in the first 30 days. The penalties apply to specific conditions for CMS recipients including acute myocardial infarction, heart failure, coronary artery bypass graft