...Medicare and Medicaid Reimbursement for Primary Care Introduction The Social Security Act of 1965 created Medicare and Medicaid, which provides health care coverage for the elderly, poor, and disabled. Medicare has become the largest single payer health entity spending $57.9 billion in 1980, $271 billion in 2003, and $513 billion in 2010 (Social Security Administration, 2012). Whereas, Medicaid being state funded, its governance is state-specific for spending. There have been very few changes to The United States health care payment system since Medicare’s and Medicaid’s inception, until March 23, 2010, when President Barac Obama signed into law the Patient Protection and Affordable Care Act (ACA). The three main goals of the ACA are to: increase the access to health care for all Americans, increase their quality of care, and make this care affordable. Unfortunately, despite the ACA’s good intent, its scope was far reaching, glossed over current problems within health care, and created more issues. It is filled with contradictory verbiage that required multiple teams of lawyers to decipher (with many different interpretations), and changed health care reimbursement with unknown consequences. Description of Policy and the Legislation The ACA attempts to solve the reimbursement problems in several ways. The act established the Center for Medicare and Medicaid Innovation within the Centers for Medicare and Medicaid Services, which is responsible for overseeing voluntary...
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...Abstract The Affordable Care Act (ACA) brings a myriad of changes to the healthcare system and hospitals must adapt accordingly or face dire financial challenges. Some of the financial challenges will originate from the influx of Medicaid patients due to the Medicaid expansion. Based on these changes, there is an increased tendency for hospitals to engineer ways to reduce costs such as patient selection and staff reduction. However, for a hospital to participate in Medicare, which accounts for more than 50% of hospital budgets, certain laws and regulations must be followed. This paper discusses these laws and regulations and offers suggestions on how to adjust successfully to the upcoming changes. The Affordable Care Act (ACA) and Hospital Compliance In light of the current changes in the healthcare industry, it is imperative for every healthcare organization to adapt accordingly or face dire financial challenges. A major change included in the Affordable Care Act (ACA) is the expansion of Medicaid, which will provide coverage to millions of formerly uninsured US citizens and permanent residents (Rosenbaum, 2011). However, Medicaid is notorious for much lower reimbursement compared to Medicare and private/commercial insurance (M. Schmitt, personal communication, October 7, 2013). In addition, hospitals are now required to prove that the services they bill for actually improve and maintain patients’ health (Leonard, 2013). Hospitals are also required...
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...Medicare Fraud: The History, Incidence, Costs and Institutional Remedies INTRODUCTION In 1965, President Lyndon B. Johnson signed the Medicare Act into law. The purpose was to provide healthcare to individuals the age of 65 or older or individuals under the age of 65 diagnosed with specific medical conditions (Center for Medicare and Medicaid Services, 2013). The original intent was to provide immediate payment to those providing medical services for the less fortunate. The Medicare Act has since been revised to meet the current needs of the American population as well as the United States economy. In part, these revisions included identifying, combating, establishing punishment (criminal laws) and prevention for Medicare Fraud. This paper will provide a brief overview of the Medicare fraud history, incidence, costs and institutional remedies. MEDICARE FRAUD: HISTORY AND DEFINITION Fraudulent activities against the government were first addressed during the Civil War. The False Claims Act (qui tam statute), also known as the Lincoln Act, was passed during this time frame. The intent was to prevent the Union Army from being a victim of supplier fraud. Citizens were given, “the ability to file suits on behalf of the US government whenever they spotted fraud” (Medicare Fraud Center, 2015). The citizens were rewarded with a portion of the monetary fines (issued to the defendant) for addressing the crime. Currently, similar rewards remain in effect for reporting Medicare...
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...Stephanie Myers December 4, 2014 The Affordable Care Act and Medicaid Reimbursement Shortcomings Fewer physicians are accepting new Medicaid patients today, mainly because of low reimbursement rates and the large increase in the number of Medicaid enrollees. As many states have expanded Medicaid in response to the Affordable Care Act (ACA), which promises additional federal funds for a number of years, the number of Medicaid patients has increased dramatically. The problem is Medicaid only reimburses doctors about 60 percent of what private insurers pay (Glans, 2014). Many physicians limit the number of Medicaid patients they serve in comparison to those with private insurance because they simply cannot afford to take too many patients receiving subsidized care (Glans, 2014). Unfortunately, some refuse to accept any Medicaid patients, and with the shortage of primary care providers, is access really improving? Insurance officials recognize the reduced rates in some plans, and express are under enormous pressure to keep premiums affordable. They believe that physicians will make up for the lower pay by seeing more patients, since the plans tend to have smaller networks of doctors. From the provider perspective, if a rate has already been negotiated from insurance, it should be the same on or off the exchange since the same services is being provided (Rabin, 2013). Yet many physicians complain of not being able to see their current patients, so it is unlikely public insurance...
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...Medicare is a national government-sponsored health insurance program in the United States of America. On July 30, 1965, President Lyndon B. Johnson signed Medicare into law in Independence, Missouri. Medicare offers health insurance for Americans aged 65 and older. It also provides health insurance to younger people with disabilities, end-stage renal disease, and ALS. Medicare is the primary insurer for 54 million Americans. Medicare is a single-payer health care program, covering all eligible beneficiaries under a single, publicly financed insurance plan. Government spending on Medicare in 2013 was $583 billion, or 14 percent of the federal budget (Centers for Medicare and Medicaid Services, 2014). Hospitals, healthcare providers, and suppliers participating in the Medicare program must meet minimum health and safety standards. The standards are defined in the Code of Federal Regulations, Title 42. The Centers for Medicare & Medicaid Services (CMS) defines Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) that set the standards that health care organizations must meet to begin, and continue participating in Medicare. CMS currently has approved seven accrediting organizations that can accredit a heath care organization as having “deemed status”. The national accrediting organization surveys a health care organization and certifies that they satisfy the health and safety standards component of the Medicare certification (Centers for Medicare & Medicaid Services...
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...facilities rely on JCAHO accreditation procedures to indicate to the public that their particular institution meets quality standards”(JCAHO). JCAHO and its policies have taken on a real importance in the medical field, despite the lack of official government sanction. The Joint Commission is an independent, private sector in the United States that administers accreditation programs for hospitals and other healthcare-related organizations. The Commission develops performance standards that address crucial elements of operation, such as patient care, medication safety, and infection control and consumer rights. Most state governments require that healthcare organizations be accredited by the Commission as a condition for licensing and Medicaid reimbursement. JCAHO evaluates and accredits approximately 18,000 health care organizations, including hospitals; ambulatory surgery centers (ASCs), health care networks, and clinical laboratories. The Joint Commission was founded in 1951 as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Joint Commission Resources (JCR), a global affiliate group, oversees the Joint Commission International (JCI). In this essay I will continue to use the monopolistically...
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...National Health Reform - Decreased Cost in Medicare and Medicaid: How Does it Impacts Nursing Home Care in New York State by Vina Aileen Bonner HCA 621 Utica College Fixing medical care and health insurance in the United States has been a public policy concern for about a century. Presidents such as Theodore Roosevelt, Harry S. Truman, John F. Kennedy, Richard Nixon, Jimmy Carter and Bill Clinton focused on the National Health Reform, but only President Barack Obama achieved the health care reform. Health care costs are increasing while the access to health care is declining. The occupationally based health insurance system is greatly stressed. Medicare and Medicaid are consuming more of the federal budget. According to the White House’s budget for U.S. Department of Health and Human Services (HHS), President Obama’s proposal would save nearly $360 billion in Medicare and Medicaid over the next 10 years: $56 billion would come through Medicaid reforms. Medicare is a federal health insurance program providing health care benefits to all Americans age 65 and over. Medicare is a significant part of the reason the national debt is soaring out of control. It is an open-ended program for provided for millions of senior citizens and people with disabilities. Medicare is growing faster than Social Security and more expensive in the next 25 years. Nationally, health care experts believe that as much as third of all health care spending – about $800 billion in...
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...Mark Cahen Health Economics HSA510 Case Assignment #2 Reimbursement Methods and Hospital Finance Dr. Rashida Biggs 02/24/2011 Good Afternoon staff, Today as I stand before you we are here to discuss our financial difficulty and ways we might be able to rise up from these hard times, First, Medicare patients whose hospital stays are paid through Diagnostic Related Groups (DRGs) which are a set of case types established under the prospective payment system (PPS) identifying patients with similar conditions and processes of care. CMS is in the process of adopting a new set of 745 Medicare Severity Long-Term Care Diagnostic Related Groups (MS-DRGs) that replace the existing 538 DRGs with ones that better recognize the severity of the illness. This was developed for Medicare as part of the prospective payment system. According to author Rick Mays, “Rather than simply reimbursing hospitals whatever costs they charged to treat Medicare patients, the new model paid hospitals a predetermined, set rate based on the patient's diagnosis. The most significant change in health policy since Medicare and Medicaid's passage in 1965 went virtually unnoticed by the general public. Nevertheless, the change was nothing short of revolutionary. For the first time, the federal government gained the upper hand in its financial relationship with the hospital industry. Medicare's new prospective payment system with DRGs triggered a shift in the balance of political and...
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... |(Private Insurance, self-insured employers, Managed Care |(Medicare, Medicaid, State Children’s Health Insurance Program [SCHIP]) | | |Organizations) | | |Access for who: |Private insurance provides access to employees whose employer,|Medicare is for individuals 65 years or older. Medicaid are for families | | |union or organization qualifies for group insurance. |with children in the Temporary Assistance for Needy, the elderly, blind, | | |Self-insured employers provide access to its employees and |and disabled with low incomes, and children and pregnant women whose income| | |managed care organizations provide access to its’ insured (Shi|is 133% below the Federal Poverty Level (Shi & Singh, 2008). SCHIP provides| | |& Singh, 2008). |access to children under the age of 19 whose family income exceeds Medicaid| | | |threshold levels (Shi & Singh, 2008). | |Coverage provided: |Coverage is provided for ambulatory patient services, |Medicare Part A covers inpatient hospital visits, skilled nursing facility | ...
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...and OSUWMC North hospitals and several clinics throughout Ohio. Recommended ways to increase these scores will be provided. Interviews with vital (OSUWMC) management took place and ideas, as well as, results revealed the purchase of electronic medical record (EMR) system, with computerized prescriber-order-entry (CPOE) capabilities, along with an automated call distributor (ACD) line would increase the patient’s experience enhancing this upcoming year’s patient satisfaction scores. The new Affordable Care Act will be discussed and how it will affect any hospitals reimbursement because a vast majority of the patients being serviced will now qualify for more Medicaid programs than last year. This patient population has been determined to be indigent, not having any source of income or insurance to pay for their hospital bill. Research shows that if hospitals are not in alignment with the CMS Medicare and Medicaid patient satisfaction rules and regulations, we could lose this patient population and funding. It was expressed in the interviews with (OSUWMC) management that if the customer service training was more consistent and received additional resources the patient experience would have a greater impact on the responses on the questionnaires, drawing a more positive direction with the hospitals scores and cultural direction. The Research The primary research took place with interviews with a customer service manager and a financial manager of OSUWMC hospitals that provided...
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...Children’s Health Insurance Program Tracy D Cotthoff Western Governors University Table of Contents Abstract 3 History of Children’s Health Insurance Program 4 The Impact of Licensure, Certification and/or Accreditation on CHIP 7 CHIP Reimbursement 8 Clinical Quality 9 Patient Access to CHIP 10 CHIP Impact on the Workforce 11 References 13 Abstract Americans have always had an insurance gap, but the hardest hit seem to be the children. There was a program created to try to fill that gap. Children’s Health Insurance Program was created to insure children that would otherwise be without health coverage. This program was started under Medicare to ensure that children would have medical, dental, vision, prescription, substance abuse and some mental benefits. History of Children’s Health Insurance Program The following is the history and facts of the Children’s Health Insurance Program: * In 1997, The Children's Health Insurance Program (CHIP) was created via federal law. For children’s families that have income above the Medicare limits, this program helps states to provide health insurance to uninsured, low-income children living with families. * The original CHIP funding for fiscal years 1998 thru 2008 was between $3.1 billion and $5.0 billion. The federal and state governments share in the cost for CHIP, and states have leeway in setting criteria for eligibility and which healthcare services to cover. * By 2007, 13 states had expanded...
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...office providing the care. The ambulatory medical records system can be designed to include billing, coding, and transcription of physician notes. The benefits of the AMR are physicians can also increase compliance to standard and guidelines of diseases, increase time spent with the patient, and reduce space needed in offices for paper charts. Computerized Medical Record A computerized medical record (CMR) is the health information and data about an individual stored within a computer. The use of computerized medical records recently has been a requirement from the government and the CMS to receive payment for services rendered. The use of computerized medical records has advantages like faster retrieval of patient records, faster reimbursement process, legibility of doctor notes, and better organization of information. The CMR can include information currently obtained on paper and old patient records still in paper format; by scanning...
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...for Medicare and Medicaid Services Centers for Medicare and Medicaid Services Centers for Medicare and Medicaid, once called the Healthcare Financing Administration was signed into law on July 30, 1965 by President Johnson. The Medicare and Medicaid programs were created under the social security act to provide health insurance to people with disabilities, low income families, people 65 or older, or people with terminally ill disease. Medicare was once the responsibility of Social security administration, and Medicaid was once the responsibility of the Social and Rehabilitative Service Administration until in 1977 the Healthcare financing Administration was created administer both services. What led the production of these two health insurances was the belief in the 1940s that everyone is entitled to health insurance no matter what, but since then health care cost has risen drastically. Many health care providers are reluctant to offer services or the appropriate services to people with this type of insurance because only a set amount is covered and not all expenses are paid for. In America Medicaid and Medicare provide health insurance to millions of people every day, and it would be devastating if they failed and were no more, throughout this essay I will show shocking statics and facts on both of these health services and how they work. It is important for Americans to be knowledgeable on what our country’s health runs on and how financially Medicare and Medicaid affect...
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...Classification of Diseases, Ninth Revision, Clinical Modification- A coding system to classify disease data by disease information or procedure information for clinical information; The coding system assist with reimbursement of services provided by facilities. • The most important aspect of ICD-9 coding system is it defines disease in category allowing medical personnel to determine diagnosis, disorders, and procedures incorporating patient data and can assist in utilization process. CPT- Current Procedural Terminology- CPT is another coding system to document medical services, surgical procedures, and diagnostic procedures. CPT codes are HCPC codes that can identify what has been done to a patient to assist in the diagnosis and prognosis of the patient by physicians, billers, coders, and administrative personnel. • The importance of CPT codes is it is a uniformed coding system for medical personnel to document accurately and maintain records for billing and diagnostic purposes. CMS- Centers for Medicare and Medicaid Services- An agency within the Department of Health and Human Services that administers the Medicare and Medicaid program and standards for HIPPA. • The importance of CMS is it provides the different standards that Medicare and Medicaid providers must adhere to. CMS-1500- Health Insurance Claim Form- Health insurance claim form physicians and facilities use to process procedures and services rendered to patients. • The importance...
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...Medicare is a federal government payer program for people over 65, for people with certain disabilities, and people with end stage renal disease. The program was started in 1966 by President Lyndon Johnston under the Social Security Act. Medicare is the largest of the government payer program in the United States. Because of this, Medicare has a large impact on licensing, certification and accreditation standards. Every health care facility is required to be licensed to provide care to patients. Each state has different requirements for a facility to be licensed and they can change annually. In the state of Washington, the Department of Health is responsible for licensure of hospitals. Healthcare facilities are licensed to make sure that the facility meets certain standards of service and quality and that the facility meets with state laws and regulations. After receiving their initial license, a facility will be periodically reviewed to make sure that the standards are continued to be met. If a facility wants to provide care to Medicare patients, it must first be licensed to provide care within the state they are located. Any health care facility that wants to provide care or services to Medicare patients and be paid by Medicare, must be federally certified in addition to being state licensed. Medicare certification is voluntary. Certification is when an outside agency officially determines if a health care facility meets the Social Security Act's provider or supplier...
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