Impact of CMS Regulations and Reimbursement Models
The Health Care Industry HCM307-1802B-03
Unit 1- Individual Project 1
Michael Green
May 22, 2018
Introduction
Healing Hands Hospital is preparing financially for the many different reimbursement changes associated with Medicare Advantage Plans. My financial team and I, have been asked to evaluate our current billing and operations workflow processes and incorporate the current trends. We will be discussing how Medicare Advantage affects Healing Hands Hospital, and how we can utilize these trends to maximize patient care.
Organizational Budget
Reimbursement and financial trends will change go hand and hand. The Healing Hands Hospital needs to rely on the revenue
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If the patient shall say longer they are more than likely to get even sicker or can catch an infection and their health should diminish prolonging their stay. This scenario is not good for any business. The length you stay in the hospital is very costly, in regards to the hospitals budget and income, we do want to see as many of our patients as possible. We want to be able to get out patients checked in and out in a timely fashion, so that we run less risk of additional sickness and …show more content…
For example, hospitals can ensure that all written policies for assisting low-income patients are applied consistently. In addition, hospitals can review their current charge structures and ensure that they are reasonably related to both the cost of the service and to meeting all of the community’s health care needs. Finally, hospitals could also implement written policies about when and under whose authority patient debt is advanced for collection.
The Financial Impact of MACRA
In typical bundled payment models, providers and payers share in savings and/or losses. When actual health care costs fall below the lump-sum payment, both parties keep a portion of the difference as additional profit. Conversely, the provider must provide extra services at a loss when health care costs exceed the lump-sum payment, though payers mitigate some of this loss. The potential for savings for payers lies in upfront discounted payments for episodes of care, as well
How ICD-10 impacts the revenue cycle management by Sashi Padarthy discusses the “opportunity” for facilities to improve on “clinical documentation, revenue cycle performance, and analytic capabilities for business intelligence” (Padarthy, July 2012, p. 7). Padarthy suggests the shift from ICD-9-CM to ICD-10 will require multi-departmental assessments to determine core factors within ICD-10 will that will directly influence coding, billing and reimbursement. Padarthy proposes facilities analyze their current diagnostic and procedural codes to assess whether their current codes accurately represent services provided. In addition, he asks facilities to determine “if an opportunity to leverage ICD-10” exists, and if so, what is needed; updated eligibility requirements, increased medical necessity
HF is not only detrimental to the patient but also impacts funding, reimbursement methods, economy, businesses and cost of our society. The rate of HF readmissions will continue to increase with time due to the aging population. Implementing strategies to offset these causes are important for the financial growth of healthcare today. Elimination of all probable causes prior to discharge will result in evidence based outcomes and promote a longer lifespan.
HCPCS codes facilitate the procedure of processing health insurance claims made by insurers such as Medicaid. The HCPCS is divided into two levels or classes. The task of classification lies with the Centres of Medicaid and Medicare Services (CMS) in association with the HCPCS work group and other third party payers. Classification is done quarterly, marking a significant step-up from its previous system of annual updates. Since 2014, the CMS has been implementing several changes regarding the continuation of HCSPCS level II.
Payers will cover more procedures, reject less, pay faster, and reimburse more
Perry Ashilevi, HADM 555, Fall 2016(Instructor: Scott Perryman) Reading Assignment #1: Modern Healthcare Article Topic: “Divided Over Bundled Payments” by Elizabeth Whitman, September 28, 2016. In the Modern Healthcare article “Divided Over Bundled Payments”, the author Elizabeth Whitman suggests that there is a separation between payers and providers as to the direction of bundled payment models. As a result of the passage of the Affordable Care Act in 2010, the author asserts that bundled payment is becoming more popular for value based payment in the healthcare industry.
III. Arguments for Narrow Networks While narrow network health plans are partly the result of a response to regulations in the ACA by insurers and health systems, they are also the product of changing market conditions in the healthcare industry over the past 10 -15 years. First of all, the backlash against managed care plans in the nineties led to the effects of selective contracting being eroded as provider networks were expanded and benefit design enhanced to allow members to see providers outside the network (albeit with a higher cost share). One consequence of this expansion of provider networks has been the increase in insurance premiums. Another contributing factor to higher insurance premiums has been increased consolidation as hospitals and physician groups have merged forming larger entities and as a result increased market power which in turn has enabled these merged entities to negotiate higher prices with insurance companies (Morrisey, 2009).
Billing 1 Week 2 DB Discuss the importance of knowing the processes and procedures used for receiving payment for services rendered under the contract provisions. It’s extremely important to understand both the process and procedures of securing payment for medical services under a managed care contract agreement. The process for receiving payment for services begins when the patient makes their initial appointment with a provider.
Also, CMS entered into an agreement with FMQAI – Florida Medical Quality Assurance, Inc to issue services for Medication Measures Special Innovation Project. Nevertheless, this project created measures to assist quality healthcare delivery to Medicare beneficiaries. There are five Centers for Medicare and Medicaid services Small Entity Compliance Guides. First, a guide has to be prepared when an organization gives final directives by preparing a Final Regulatory Flexibility Analysis under the Regulatory Flexibility Act. Second, organizations are desired to publish compliance guides on their websites, and share guides with affected individuals.
The topic being researched in this paper is the Maryland All Payer Model. The reason for reviewing this topic is to better understand the payment system for the state in which I live. I was born and raised in the state of Maryland. Like other residents of Maryland and an insurer, I not always as aware of the things that affect me personally. In conversations had, along with some understanding of the process of how the revenue cycle works, I believed that not only would this be a topic that can bring personal awareness for myself but also help to understand the Maryland payer system for career growth.
I want to participate in efforts to end the days people refuse to seek care in fear of taking loans or ruining their credit score because they have to declare bankruptcy. Health is a basic human right and Americans shouldn’t have to decide between seeking medical help or supporting themselves. In order to make effective contribution to improving healthcare, I will need to learn as much as I can from my colleagues, professors, patients, and school administration. The school dean, Larry Kaiser, has been instrumental in the financial transformation of Temple University Hospital, turning a fiscal deficit into surplus. Dr. Kaiser has a heart to advocate for those who may not have the resources or time, and I want to practice that philosophy.
The cost of healthcare has increase exponentially through the years. Current government reimbursements are lower than the actual cost to provide healthcare services. Businesses are falling short of their revenue and are limited to the amount of money they received from Medicaid and Medicare. Limited revenue has lead to the common practice known as cost shifting, which accommodates for the losses of revenue and for uncompensated care. Cost shifting has been a matter of controversy.
Physicians and Hospitals go hand in hand when it comes to the medical care of patients, and it is this relationship that allows the patients to receive the care they need and deserve. It is also this relationship that we as health care administrators need to understand. In order to fully understand this relationship we need to define the concept of the integrated physician model. We also need to explain the importance of clinical integration in the strategic planning process, and the dynamics of and controversies surrounding accountable care organizations and alternative approaches to the current health system. I will also explain the advantages and disadvantages for hospitals and physician’s models.
Patient with critical condition need to be considered as they need to be closely monitor by health professionals in the hospital. The Consultation document ‘Care in the Community’ (DHSS, 1981) made several suggestions for moving people who do not need nursing care out of long -stay hospital (Social Policy and Social Welfare, 1983). By limiting services, NHS is trying to increase its care to what it may be refer as ‘treatment’. Giving priorities to both conditions are necessary but doing this by choosing the right environment and what is best for patient is more important. In family members, it might affect elderly people that might require help such as nursing care.
Previously, majority of healthcare systems were driven by other goals such as ensuring enhanced care access, containing the costs of healthcare delivery, and promoting patient convenience/customer service in a bid to improve the efficiency and quality of healthcare. However, the financial collapse had far-reaching consequences for the healthcare systems as it
Sister Elizabeth had raise the issue in their view, each case is unique, and different and only attending physician can determine what length of stay or total expenditure the advantages can be patient’s short length of stay whose care is different or less severe condition. It can save the total of cost for each case. If they having every unique case, separately create an outpatient area for those patient with less care. Or service without having a stay.