...Pay-for-performance and Reimbursement Jason Teker HCS/531 May 2, 2016 Georgetta Baptist Pay-for-performance and Reimbursement Health care is in the middle of a change in how payment is received for services provided. Fee-for-service is the dominant form of reimbursement for hospitals and doctors. According to Medicaid’s website, the fee-for-service payment model is structured so that there are incentives in place based on the number of services provided. Fee-for-Service models allow for a system where quantity is more important than quality. With rising health care costs, the federal government is looking to change the way hospitals and doctors are reimbursed for their services. Quality health care is becoming a hot topic in many realms of the health care industry. The government has proposed a new form of repayment in a system called Pay-for-performance which was brought to the forefront of policy agendas by the Institute of Medicine’s (IOM) report in 2000 titled To Err is Human (Mayes, 2006). In the report, the IOM estimated “as many as 98,000 patients die annually in U.S. hospitals due to preventable medical errors” (Mayes, 2006, p.17). Pay-for-performance is “a reimbursement method under which some physicians and hospitals are paid more than others for the same services because they have been deemed to deliver better quality care and their patients appear to have better outcomes” (Mayes, 2006, p.17). With this new reimbursement method, the incentives are now...
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...Healthcare Reimbursement Anne B. Casto, RHIA, CCS Elizabeth Layman, PhD, RHIA, CCS, FAHIMA Copyright ©2006 by the American Health Information Management Association. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, photocopying, recording, or otherwise, without the prior written permission of the publisher. ISBN 1-58426-070-X AHIMA Product No. AB202006 Ken Zielske, Director of Publications Susan Hull, MPH, RHIA, CCS, CCS-P, Technical Reviewer Marcia Loellbach, MS, Project Editor Elizabeth Lund, Assistant Editor Melissa Ulbricht, Editorial/Production Coordinator All information contained within this book, including Web sites and regulatory information, was current and valid as of the date of publication. However, Web page addresses and the information on them may change or disappear at any time and for any number of reasons. The user is encouraged to perform his or her own general Web searches to locate any site addresses listed here that are no longer valid. AHIMA strives to recognize the value of people from every racial and ethnic background as well as all genders, age groups, and sexual orientations by building its membership and leadership resources to reflect the rich diversity of the American population. AHIMA encourages the celebration and promotion of human diversity through education, mentoring, recognition, leadership, and other programs. American Health Information...
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...Comparison Reimbursement Programs and the Movement of Finances in the United States Health Care System by Ronald J. Sanders MBA520, MBOL2, Health Care Organization Instructor: Dr. Sandra Washington Saint Leo University Distance Learning March 17, 2013 Abstract Effective payment program strategies are a major part of administering health care. Reimbursement programs are a part of the United States (U.S) health care system. They represent a financial tool for providing cash flow to service physicians and hospitals. Many times, the ability to provide quality health care depends on the payment for the services given by physicians and hospitals. This paper presents a view of payment reimbursement systems within the health care industry. A comparative overview and description of payment reimbursement will be given in order to understand the flow of finances in the health care industry. The focus will be on the capitation and fee-for-service reimbursement systems. Readers will then be able to conclude that the appropriate reimbursement method is dependent upon the amount of risk a party is able to assume. Comparison of Reimbursement Programs and the Movement of Finances in the United States Health Care System Physicians that are part of the managed care system have several methods in which to be compensated or be reimbursed for services. Two popular methods are Capitation and Fee-for-Service. Physicians have confronted several challenges...
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...hospital, they can be linked together to show visits in the ambulatory setting. The medical records are kept at the office that provides the care (Wager, Lee, & Glaser, 2009). The AMR system includes billing, coding, and the transcription of doctor’s notes. AMR’s are important because they can ensure compliance, increase the time which doctor’s spend with their patients, and reduce the space in the offices for paper charts. * CMR- Computerized Medical Records are health information about patients stored within the system. Recently, the use of computerized medical records has become a requirement for the government and CMS in order to obtain reimbursements for services rendered (Wager, Lee, & Glaser, 2009). CMR’s are important and increases reimbursement time processes, increases retrieval times of patient records, makes physician handwriting more legible, and assists with organization of patient information. The CMR includes information that was previously obtained by scanning the patient chart into the computer system. * CMS- Centers for Medicare and Medicaid focuses on physicians, nursing homes, long-term care, home care and hospitals. They ensure compliance of government policies and procedures of these facilities. CMS aggregates data from CMS1500 (Insurance claims forms) for analyzing national health care reimbursements as well as clinical and population trends (Wager, Lee, & Glaser, 2009). * CMS-1500 is an insurance claim form adopted by the federal...
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...Managed Care Lucille Purry Economics of Healthcare Faculty Sever South University 10 December 2013 Abstract Managed care, a deliver system for health care intended to reduce the cost of that care. Examples of managed care organizations are HMO, IPA, PPO, POS and PFFS. MCO’s operate through contractual agreements that are set to meet certain standards due to the fact that they don’t have direct control. Managed care provider and hospital reimbursement ranges from fee for service and capitation. Episode-of-care is where providers receive one lump sum for all the services they provide related to a condition or disease, and capitation is where the third party payer reimburses providers a fixed amount for a period. There are many other forms of reimbursement between these two methods and vary depending on service. Risk – based payment applies to both hospitals and providers. With so many choices in health care coverage and means of payments, it becomes necessary to be sure you have a complete understanding of what is expected from you, what is covered and not covered and to be sure any treatment is necessary. Along with managed care, we have to consider how this affects Medicare and Medicaid. These have changed the healthcare system and joined together to better serve the public. Managed care; advantages and disadvantages as well as how it came to be are to follow. Managed Health Care dates as far back as 1910; one example is when the Western Clinic in Tacoma, Washington...
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...Fair reimbursement for healthcare professionals is a controversial topic. Is the clinician’s degree or the type of care provided and overall clinician’s performance that should be rewarded? In actuality, most private insurance carriers pay standard fees for service. However, Medicare is the exception because it limits the reimbursement of services provided by physician assistants (PAs) to only 85% (Wilkens, 2012). Undoubtedly, productivity and economic reimbursement are integral components of the healthcare system. Therefore, it is crucial to understand the various aspects that have shaped the reimbursement for PA services, including the Balanced Budget Act (BBA) of 1997, current reimbursement terms, and the national provider identifier (NPI)....
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...current health care reimbursement system. What components do and do not contribute to the overall effectiveness of the system? Why? * The symbiotic nature of components in the health care system * The fragmentation of the health care system * The school of thought regarding health care as a free-market good * The school of thought regarding health care as a universal right The U.S healthcare reimbursement system is very complex. It involves private and public payers and changes in the reimbursement approach of one payer have implications for the other. One feature lacking in both type of payers is reimbursement linked to quality. Payment is based on delivery of services: “Right or Wrong”. The current system does not promote quality care and most services for preventive care are not reimbursed. Those components don’t contribute to the overall effectiveness of the system. Given a clean slate, would you keep the current system, keep components of the current system or change it altogether? One thing we should keep in mind is, although not effective, the current system works! Billions of service transactions occur each year and providers receive payments that sustain them financially even though some physicians believe reimbursements are not sufficient to support their increasingly complex practices. The problem is that: * The current system leaves approximately 45 million American uninsured and a considerable number underinsured. * Health care expenditures...
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...Intro to task two: The Indian Health Service (IHS): The IHS is a health care system for nearly 2 million American Indians and Alaska Natives who belong to the 566 different, federally recognized, tribes in 35 states. 1 IHS is an agency within HHS, which is the Department of Health and Human Services. 2 The Indian Health Service was established in 1955 taking over from the Bureau of Indian Affairs. It is based on Article I, Section 8 of the Constitution and the relationship developed from numerous treaties, Executive Orders, and Supreme Court decisions 3. The IHS is the primary health care provider for the American Indian people 4, and it’s dedicated to raise their health and well-being to the highest level. Health Information Exchange(s): A Health Information Exchange is the virtualization of healthcare information electronically, and access to said information exchanged between HIE members. This data spans across organizations within a community, or hospital system, or even whole regions. HIEs facilitate transmitting protected health information to other organizations and government agencies according to national standards. HIEs often include collaboration among physicians, home health, nursing homes, hospitals, and mental health facilities. 5 Federal Employees Health Benefits Program: The FEHB Program is for Federal employees present and retired as well as their survivors. Members have the widest selection of health plans in the country. With the ability to choose...
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...field of health information technology for nursing is rapidly growing. Advancements in electronic documentation for health care, such as the electronic medical record (EMR), can be an overwhelming addition to the workload of nurses. There is resistance by nurses in use of electronic documentation (Sharifian, Askarian, Nematolahi, & Farhadi, 2014). It is this writer’s opinion that nurses are under informed regarding the rationale for changes taking place in documentation and the implications. The purpose of this paper is to provide nurses with the basics of the Federal regulations outlined in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) that require electronic documentation to be compliant and receive reimbursement. It also reviews how data are collected to determine the reimbursement for care (meaningful-use) and its role in evidence-based practice (Wright, Feblowitz, Samal, McCoy, & Sittig, 2014). Included is a review of the negative impact resistance generates on health organization reimbursement and the relevance it has on nurse staffing, jobs, wages, and satisfaction, along with, evidence reinforcing the training and support of nurses as a means to promote proper use of electronic documentation and increase user satisfaction. Federal Laws and Requirements for Compliance Health care agencies in the United States are implementing health care information...
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...Mental Health Rehabilitative Services (CMHRS) are billed under Medicaid in comparison to other industries and the impact that private and government insurers and payers have on the reimbursement process. How Medicaid is administered and funded Medicaid is a government program that is administered through the U.S. Department of Health & Human Services (HHS) in order to assist low-income people pay for part or all of their medical bills. It was created by the 1965 Social Security Act. It is federally governed but locally administered by each State. States use private health insurance companies to administer their Medicaid programs. These providers are essentially HMOs that contract with the state Medicaid department to provide services for an agreed-upon price. Other states work directly with the service providers. How to Code and Bill Medicaid for CMHRS Services In Virginia Magellan Health is the Behavioral Health Services Administrator or BHSA that the Virginia Department of Medical Assistance Services (DMAS) contracted to manage and direct Virginia’s Medicaid programs. All community mental health and rehabilitative services providers under contract with the Virginia’s Department of Medical Assistance Services must contact Magellan Health directly for information on the reimbursement and claims processing instructions. Magellan Health adjudicates claims, processes claims, and reimburses providers by the amount of units that have been billed (Magellan Health, 2015)...
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...Part II: Medicaid Reimbursement: Cost of Patient Costs matter in healthcare industry, and often, Medicaid have cut the physicians’ charge down to forty percentage of Medicaid care. Nevertheless, Medicaid reimbursement cuts are even lower, in which have affect the physicians’ decision whether to accept new Medicaid patient or not. As this matter continues, solutions are needed to restraint these matters into hands and improves the quality of services and cares. First solution is the bottom-up approach, this method usually developed from the below where the manager and sub-unit departments level to review and identify the problems within the organization. For example, as insurers fire a reimbursement program to hospital and/or physician, they enquires them to down-charges or substitute the treatments, surgeries, or any services for patient, the physician seem to be discourages and refuses to negotiate. In this case, the cost seem to be the issue that cause a rift between physician and patient through the Medicaid Reimbursement program. If, it was accepted and treated, the quality of care and services may not be what patients wanted to be and lead to mistrust....
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...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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...Reimbursement and Pay-for-Performance Darrick Poole HCS/531: Health Care Organizations and Delivery Systems February 11, 2013 Eugene Burwell Reimbursement and Pay-for-Performance In 2010, health care expenditures in the United States almost reached $2.6 trillion. This was 10 times more than expenditures spent in 1980. The rate of increase slowed in the late 1990s and early 2000s but industry experts still expect the cost of health care to increase more than the national income for some time to come. Stakeholders agree this continual financial burden is of critical importance. During the last decade, the financial woes in the United States caused many people to lose employment and others to work for much lower wages. The effects of the financial conditions increased the focus on health care spending and peoples’ ability to afford health care. The premiums paid by employees for their families increased by 97% putting further strains on employers and their workers. Baby boomers reaching retirement age increased enrollment in Medicare and Medicaid causing strain on federal and state government budgets. In 2010, health care expenditures consisted of 17.9% of the Gross Domestic Product. Over half of the nation’s health care expenditures result from hospital care, physician, and clinical services. One way the Affordable Care Act seeks to address the issues of cost is by reducing the compensation for hospital and treatment services that result in medical errors or inadequate quality...
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...Human: Building a Safer Health System.” The report catalyzed the attention of health care stakeholder groups in the nation (Stafford, 2000). The research provided a comprehensive, detailed account of health care errors and preventable deaths costing billions of unnecessary dollars in a health care system already spiraling out of control. The IOM recommended that Congress create a Center for Patient Safety within the Agency for Health Care Research and Quality for the purpose of designing a safer health care delivery system. Fifteen months after releasing the patient safety report, the IOM released “Crossing the Quality Chasm.” The report framed underlying reform necessary in the current health care delivery system to ensure patient safety. The framework sought to hold providers accountability for the quality of care they deliver. The introduction of the pay for performance (P4P) as opposed to the prior fee for service and prospective reimbursement guidelines induces delivery of care based upon performance measures. Broadly defined pay-for- performance includes any type of performance-based provider payment arrangements, including those that target performance on cost measures (U.S. Department of Health & Human Services, 2006) Reimbursement Pay-for-performance, synonymous with quality-based purchasing, bases reimbursement upon quality measures. The historic fee-for-service reimbursement plan enticed providers to maximize treatment to maximize reimbursement without capitation...
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...Reimbursement and Pay-for-Performance Tessa Zendner HCS/531 March 2nd, 2015 Georgetta Baptist Reimbursement and Pay-for-Performance Pay-for-performance programs have changed the way physicians provide care in many sectors of the health care industry. They impact reimbursement, especially in regard to Medicare and Medicaid. Pay-for-performance has effects on both the quality and efficiency of health care delivery, although its overall impact it a matter of debate. There are studies that show improvement in quality of care in some areas, and others that show no difference in outcomes. There may even be negative repercussions and ethical issues stemming from the enactment of these initiatives. The goal will be to revise and adapt the system within the evolving health care landscape in order to provide the best outcomes possible for both providers and consumers. Pay-for-performance Pay-for-performance is an incentive program defined by the Health Care Incentives Improvement Institute as, “a term that describes health-care payment systems that offer financial rewards to providers who achieve, improve, or exceed their performance on specified quality and cost measures, as well as other benchmarks” (Pay for Performance, 2012). Pay-for-performance has become a popular tool to attempt to improve quality and efficiency in health care. It is becoming more widespread with the enactment of The Patient...
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