Healthcare Ecosystems
LLT Task 2
Jacqueline Sanders
Western Governors University

Healthcare facilities are required to maintain licensure, certification, and accreditation in order to receive payments from federal government programs such as Medicare. Healthcare facilities must meet the minimum standards in order to operate, such as sufficient staffing, personnel employed to provide services, the quality of equipment, buildings, and supplies, and services provided, including health records. (LaTour, 2013) Medicare has developed Conditions of Participation and Conditions for Coverage, which identifies specific criteria that must be met in order to receive reimbursement from Medicare. Medicare implements these guidelines in order to set a standard for improving quality of care and maintaining the health and safety of its beneficiaries. (CMS, 2013)
State agencies conduct annual surveys of licensed facilties to ensure they are operating at or above the minimum standards set forth by the sate and CMS. It is imperative for licensed healthcare agencies to meet the guidelines of the Conditions of Participation in order to receive reimbursement, if they do not meet the minimum standards they could be unable to participate with Medicare, thus losing patients and revenue.

Physician Quality Reporting System requires healthcare providers and hospitals to meet clinical quality standards and record them. Physician Quality Reporting System is a program implemented by Medicare that uses incentive payments and incentive adjustments in order to promote reporting of quality information from its eligible participants. In order to receive incentive payments, the eligible provider must meet the minimum standard criteria for reporting quality information. Beginning in 2015, the program will also apply an incentive adjustment for EP’s who do not satisfactorily report data. The PQRS requirements and specific criteria may differ from year to year; it is the EP’s responsibility to stay up to date on the current specifications.

Medicare Part A reimbursement for services in hospitals and nursing home care uses Prospective Payment Systems. With this reimbursement, the hospital or nursing home receives the same flat rate for each episode of patient care, regardless of the actual amount of care that was performed. The actual amount of money that is reimbursed is based of the DRG or Diagnosis Related Groups; this is based off the primary diagnosis made at the health care institution. The “Resource-Based Relative Value Scale” is a system that measures the value of physician services. Relative Value Units indicate the value of physician work, resources, and expertise needed to provide services. RBRVS assigns every procedure performed by a physician, a relative value, that value is then adjusted by the geographic location in which the procedure is performed. The relative value is then multiplied by a fixed conversion factor to determine the amount of payment.

Good access to health care is important for any individual. Ensuring Medicare beneficiaries have sufficient access to health care is especially important, as most are seniors and persons with permanent disabilities; this population is significantly more likely to need health care services. The number of providers that participate in the Medicare program directly affect its beneficiaries. If the percentage of providers were low it would result in longer wait times for appointments and an increase of out-of –pocket expenses. Every year the Medicare Payment Advisory Commission conducts an annual survey regarding Medicare beneficiaries’ access to care, this allows Medicare to make adjustments to improve patient access to health care if needed.

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.

Medicare laws, regulations, and processes are ever changing. In order to comply with Medicare changes, HIM professionals must conform. HIM professionals play a critical role in maintaining clinical documentation; quality improvement and revenue integrity. HIM professionals are increasingly important to ensure the standards of healthcare that are set forth by Medicare are being met. The demand for Health Information Management professionals is growing across the healthcare system, including Medicare.. It is noted that there is a shortage of HIM professionals and the demand for HIM professionals will increase. The US department of Labor stated that the HIM profession is one of the fastest growing health occupations. (AHIMA) In order to comply with Medicare, HIM professionals may need to obtain different certifications, require more continuing education, and adjust their roles.

References

1. LaTour, Kathleen, Shirley Eichenwald Maki, and and Pamela K. Oachs. Health Information Management: Concepts, Principles, and Practice, 4th Edition. AHIMA Press, 2013. VitalBook file. 2. Conditions of Coverage & Conditions of Participation. (n.d.). Retrieved December 13, 2014, from http://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/index.html?redirect=/cfcsandcops/16_asc.asp 3. HIM Functions in Healthcare Quality and Patient Safety. (n.d.). Retrieved December 14, 2014, from http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049122.hcsp?dDocName=bok1_049122