...granted an “admitting privileges”; to check which insurance have better coverage when it comes to payment of charges; and to determine what are the factors that affects the hospital’s revenue in order so make predictions if ever the Board keep the hospital operational what will the expected the profit and find ways on how to increase it. In the evaluating the physician’s performances we were able make an assumption that as the number of admission increases the total charges made also increases. Through comparison we found out that among the nine physicians Physician #10 delivered the most number of admissions and made the highest amount of total charges. Also, by further analysis we have strong evidence that out of the nine physicians, Physician #2 charges the most amount per patient which also contributed an increase in the hospital’s total collection. With these findings, we made a recommendation to the hospital’s Board that Physician #10 and #2 deserved to be awarded “admitting privileges”. It is said that the hospital’s revenue depend mostly to the amount that the patient’s insurance is willing to pay. As we analyzed the given data we derived with a conclusion that most of the patients that were admitted in the hospital have Managed Care Insurance. Consequently this finding tells us that the large amount of collection came from the said insurance. We can then tell the Board that we have enough statistical data to prove that in the future there is a possibility that hospital...
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...#1…Public health IN THE United States, primary care remains a medical model. This is in contrast to much of the world, where the 1978 Declaration of Alma-At a which recognized that attaining health for all also requires interaction from social and economic sectors - is considered standard. Today, there is much buzz about patient-centered medical homes, a concept that promises to transform the practice of American medicine. There is much to praise about this most recent iteration of the medical home. But the missing ingrethent in all these definitions and models remains public health. A population focus that addresses the social determinants of health is an essential component of primary health care. In the United States, such a comprehensive approach has been labeled community-oriented primary care. This model is built firmly on the Alma-Ata principles and incorporates a public health approach to health services. Community-oriented primary care organizes the delivery of health services, around a population, not simply a collection of individuals. It identifies a population - most frequently a geographically defined community - and uses epidemiology and interventions to improve community and individual health and well-being. In this model, both individual patients and the community are the foci of the delivery of health services. Primary health care stands at the intersection of personal and population health services. It requires integrating medical models of primary care...
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...acquired Humana just recently in a merge, as well as United Health purchasing Catamaran, a pharmacy-benefits manager and prescription provider (CNN Money, 2015). It is believed the reasoning for the mergers is due to the Affordable Care Act because it has meant more business for major insurers, but the law has also put more pressure on industry profits (CNN Money, 2015). However, the merges brings a concern for physicians and the American Medical Association. Physicians fear that it will put too much power in just a handful of insurance companies and the American Medical Association says that it will reduce competition and...
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...Home Based-Medical Billing - Marketing Plan Outline 2.0 Situation Analysis Medical billing / Coding is one of the fastest growing health care jobs, The US Bureau of Labor Statistics predicts that medical coding and billing will remain among the top fastest growing occupations for many years to come. Fact is: over 500,000 practicing physicians and hospitals in the USA rely heavily on medical coders and billers for customer service, and more importantly: to get reimbursed for medical services provided to patients. (http://www.medicalcodingandbilling.com) Many Billing services currently operate to manage medical practice billing among other services offered, providing physicians with the benefit and convenience of outsourcing their billing duties to third parties in order to relieve medical professionals of the tedious and challenging work that entails medical billing and account collections. National statistics show that only about 70 percent of insurance claims, initially submitted on paper, are ever paid by insurance carriers. With the advancements of health information Systems and the increase requirement and demand for electronic submissions Claims have increased the reimbursement percentage tremendously. A survey by the American Hospital Association concluded that about 18% of medical billing and coding positions remain unfilled due to a lack of qualified candidates. Occupational trends and future outlook for Medical Billing and Coding Specialists remain at the...
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...of the scans that are ordered are deemed medically necessary. The overuse of MRIs in the US is therefore resulting in an unnecessary increase of expenses due the physicians’ tendency to practice defensive medicine. Defensive medicine is a term that refers to when a physician orders a test, procedure, or additional consultations in fear of getting sued (AP). Actually, a study showed that more than 75% of physicians in the US would encounter a medical malpractice claim during the course of their career (AP). So as this statistic shows, in the US physicians are consistently...
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...chapter, you should be able to: 1.1 Explain how healthy practice finances depend on correctly accomplishing administrative tasks in the medical office. 1.2 Compare coinsurance and copayment requirements for health Copyright © 2014 The McGraw-Hill Companies plan benefits. 1.3 Identify the key steps in the medical billing cycle. 1.4 Discuss the impact of electronic health records on clinical and billing workflow. 1.5 Evaluate the importance of professional certification and of medical liability insurance for career advancement. S te p4 Medical Billing Cycle Prepare and transmit claims 1 accounts payable (AP) accounts receivable (AR) benefits cash flow certification coding coinsurance copayment covered services deductible diagnosis documentation electronic claim (e-claim) electronic health record (EHR) fee-for-service health care claim health information technology (HIT) health plan indemnity plan managed care managed care organization (MCO) medical assistant medical billing cycle medical documentation and billing cycle medical insurance medically necessary noncovered (excluded) services out-of-pocket PM/EHR policyholder practice management program (PMP) preauthorization...
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...number of laws are in place that outlines specifically what is and is not permissible and encourages compliance with said laws. The laws that relate specifically to this topic are the False Claims Act (FCA), the Anti-Kickback Statute (AKS), the Physician Self-Referral Law (Stark Law) and the Social Security Act; in addition to those law specific to this topic, there are...
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...perform surgical procedures in office instead of at Tuomey’s 266-bed hospital. To avoid a reduction in surgical case volume Tuomey employed 19 specialists as part-time employees. They each had a 10-year contract that included: • Physicians were required to perform outpatient procedures at Tuomey hospital or facilities owned by Tuomey. • Tuomey was responsible for billing and collections from patients and third party payers, including Medicare and Medicaid. • Tuomey compensated each physician with annual base salaries that hinged on Tuomey’s net cash collection for outpatient procedures. •...
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...Malpractice Insurance for Physician Assistants Clinicians are demanded a complex level of responsibility. The nature of a collaborative practice unites midlevel providers and physicians not only in patient care, but also in any legal process that may develop as an outcome. Currently, “Litigation against physicians and non-physician clinicians (NPCs) is increasing. Claim settlements are in the millions of dollars in the aggregate for [physician assistants] PAs and [nurse practitioners] NPs” (Paterick, 2014, p. 310). PAs are at constant risk of liability; therefore, it is crucial to understand the importance of having a personal malpractice insurance and the different types of policies available. NPC’s work in collaboration with supervising physicians to evaluate and treat patients. Unfortunately, when mistakes occur and a patient is harmed, both the physician and the PA may be liable for actions or errors of others. Controversy exists “regarding how PAs' malpractice litigation risk compares with that of physicians and to what extent doctors' risk of malpractice litigation is affected by supervising PAs” (Ledges, Victoroff & Ginde, 2011, p. 35). The liability that a party holds for the actions or conduct of an associate based on the relationship of two parties is known as vicarious liability (Moses & Jones, 2011). Due to...
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...ways physicians here in the United Stated are compensated for health care services rendered to patients. In an effort to keep cost low in addition to being able to improve the quality of care to their patients, especially those with multiple chronic conditions, physicians are looking into different approaches of physician payments. A few forms of physician reimbursement are fee-for-service, fixed payments and capitation. Compensating physicians for services rendered can come in many different ways and is the choice of the health care provider which plan they choose to provide services for. One payment model would be the fee-for-service (FFS), which is a payment model where services such as physicians and health care providers are paid individually for each service performed. An example for a service would be an office visit or test (fee-for-service, n.d.). In the health care industry this form of payment gives an incentive for physicians to provide more treatments because payment is dependent on the quantity of care, rather than quality of care. Physicians are paid on fee-for-services bases at the highest rate; full cost of each service rendered. (Health Plan Payment Methods, n.d.). This payment model is based on the resourses physicians use, order and prescribes rather than the outcomes, it encourages...
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...0 3 0 Electronic Health Records in the Physician Office CHAPTER OUTLINE Patient Flow in the Physician Practice Step 1. Pre-Visit: Appointment Scheduling and Information Collection Step 2. Patient Check-in and Payment Collection Step 3. Rooming and Measuring Vital Signs Patient Examination and Documentation Step 4. Patient Checkout Step 5. Post-Visit: Coding and Billing Post-Visit: Reviewing Test Results Coding and Reimbursement in Electronic Health Records Computer-Assisted Coding Clinical Tools in the Electronic Health Record Decision-Support Tools Tracking and Monitoring Patient Care Screening for Illness or Disease Identifying at-Risk Patients Managing Patients with Chronic Diseases Improving the Quality and Safety of Patient Care with Evidence-Based Guidelines E-Prescribing and Electronic Health Records Keeping Current with Electronic Drug Databases Increasing Prescription Safety Saving Time and Money LEARNING OUTCOMES After completing this chapter, you will be able to define key terms and: 1. 2. 3. 4. 5. 6. 7. 8. 9. List the five steps of the office visit workflow in a physician office. Discuss the advantages of pre-visit scheduling and information collection for patients and office staff. Describe the process of electronic check-in. Explain how electronic health records make documenting patient exams more efficient. Explain what occurs during patient checkout. Explain what two events take place during the post-visit step of the visit workflow. Describe the advantages of computer-assisted...
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...0 3 0 Electronic Health Records in the Physician Office CHAPTER OUTLINE Patient Flow in the Physician Practice Step 1. Pre-Visit: Appointment Scheduling and Information Collection Step 2. Patient Check-in and Payment Collection Step 3. Rooming and Measuring Vital Signs Patient Examination and Documentation Step 4. Patient Checkout Step 5. Post-Visit: Coding and Billing Post-Visit: Reviewing Test Results Coding and Reimbursement in Electronic Health Records Computer-Assisted Coding Clinical Tools in the Electronic Health Record Decision-Support Tools Tracking and Monitoring Patient Care Screening for Illness or Disease Identifying at-Risk Patients Managing Patients with Chronic Diseases Improving the Quality and Safety of Patient Care with Evidence-Based Guidelines E-Prescribing and Electronic Health Records Keeping Current with Electronic Drug Databases Increasing Prescription Safety Saving Time and Money LEARNING OUTCOMES After completing this chapter, you will be able to define key terms and: 1. 2. 3. 4. 5. 6. 7. 8. 9. List the five steps of the office visit workflow in a physician office. Discuss the advantages of pre-visit scheduling and information collection for patients and office staff. Describe the process of electronic check-in. Explain how electronic health records make documenting patient exams more efficient. Explain what occurs during patient checkout. Explain what two events take place during the post-visit step of the...
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...hospital as an Inpatient, the reimbursement falls under the Inpatient Prospective Payment System (IPPS). In contrast, when a patient is admitted to the hospital as Observation, Medicare pays the hospital under the Outpatient Prospective Payment System (OPPS). The care provided is the same regardless of the Inpatient or Observation status assigned. The doctor must decide whether it is suitable to admit the patient as an Inpatient or Outpatient based on the 2 MN Rule criteria provided by CMS. The beneficiary is responsible for a one-time deductible if admitted (and billed) as Inpatient, but conversely will be responsible for a copayment on each individual hospital service if admitted (and billed) as Observation. CMS states the rule was introduced to provide greater clarity to the physicians and limit the use of observation status to reduce Medicare patient expenses. Implementation During the delay, CMS decided to conduct a "probe and educate" effort during which the Medicare claims processing contractors would review hospital's inpatient claims to determine the appropriateness of the inpatient admission under...
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...Physician Reimbursement Case Case Study Discuss the general differences between facility and nonfacility 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? 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, practice expense, and malpractice. Procedures that can be performed in either a facility or non-facility setting have different practice expense RVUs, depending on the place of service. Therefore, the practice expense is a major component in rate determination, because place of service is part of this practice expense component. The practice expense component includes rent/lease of space, supplies, equipment, and clinical and administrative staff expenses. In a general sense, facilities are hospitals, skilled nursing facilities, nursing homes, or any other place that bills for Medicare Part A. Some physicians work out of a hospital owned facility, meaning that they are employed by and work in a facility owned and billed for by a hospital, and those physicians would be billing based on the facility...
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...medical records are currently paper-based, making these records very difficult to access and share. It has been said that the U.S. health care industry is the world’s most inefficient information enterprise. Inefficiencies in medical record keeping are one reason why health care costs in the United States are the highest in the world. In 2012 health care costs reached $2.8 trillion, representing 18 percent of the U.S. gross domestic product (GDP). Left unchecked, by 2037 health care costs will rise to 25% of GDP and consume approximately 40 percent of total federal spending. Since administrative costs and medical recordkeeping account for nearly 13 percent of U.S. health care spending, improving medical recordkeeping systems has been targeted as a major path to cost savings and even higher health care quality. Enter electronic medical record (EMR) systems. An electronic medical record system contains all of a person’s vital medical data, including personal information, a full medical history, test results, diagnoses, treatments, prescription medications, and the effect of those treatments. A physician would be able to immediately and directly access needed information from the EMR without having to pore through paper files. If the record holder went to the hospital, the records and results of any tests performed at that point would be immediately available online. Having a complete set of patient information at their fingertips would help physicians prevent prescription drug interactions...
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