Reimbursement Methodologies

Reimbursement Methodologies

3 Pages, 3 Sources, MLA Style

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Health Information Management Technology-Textbook Second Edition
Reimbursement Methodologies
Part A: Answer each of the following questions in a short paragraph. Each answer is worth 20 points.

1. Youre the new director of a hospital health information management department. The chief financial officer has hired you for your expertise in health care reimbursement and needs to know how your department can help with reimbursement. List the most important functions of health information management.

            Some of the functions of the helath information management include:-

Develop, maintain and update the format of medical records and clinical documentation

Review the content and manual for the EMR’s

Develop and maintain policies and procedures regarding the EMR’s and also educate the staff members

Ensure that the EMR’s are stored and secured in a safe manner and are accessible when required

Enduring a review process and an auditing system exists with relation to the EMR system

Ensure that the patient information is appropriately coded to ensure that the information is available for billing purposes

Ensuring a process to address errors in the medical records is available
Ensure that the laws, rules, regulations and the standards compiled by the appropriate accreditation organization are met (Curry).

2. Describe the importance of Blue Cross and Blue Shield plans in the evolution of health care coverage.
The Blue Cross and Blue Shield (BCBS) consists of 39 independent helath insurance companies that operate locally in various communities and was originally started in the 1920’s.  It covers the healthcare costs for more than 100 million people in the US.  In the insurance industry BCBS is one of the most recognized brands with relation to healthcare.  The headquarters of BCBS is located in Chicago.  More than 150, 000 staff members are employed by BCBS and it also covers for helath insurance costs for many corporate employees.  In several states of the US, BCBS act as insurance agencies taking care of Medicare, the Federal Employees Health Benefit Plan and also providing group insurance to the government employees of various states.  It also covers several clients under managed care and PPO.  BCBS has formed a vital relationship with the government (at the state and the federal level) and also participates in policy-making for healthcare.  BCBS also works for non-profit and social purposes, by including certain packages for the public benefit.   BCBS also works towards improving the quality, outcome and access to healthcare and in this way has helped in the evolution of healthcare in the US (Blue Cross and Blue Shield).

3. Explain why the lack of universal health care coverage can raise health care costs.

            Currently, in the US, about 45 million of the populations are uninsured and a greater number are under-insured.  In the year 2000, about 69 % of the employers provided insurance, and in the year 2005, this figure dipped to 60 %.  Through Universal healthcare coverage, the entire population would be guaranteed free healthcare.  As the uninsured would be using healthcare facilities, more than 34 to 69 billion dollars would be spend each year.  Universal healthcare coverage would also aim to cover for out-of-the-pocket costs of healthcare, which currently is 35 % for the uninsured and 20 % for the insured populations.  This would result in shifting of the costs meet by the uninsured to the government.  Each year in the US, about 34.5 billion dollars are spending on uncompensated care.  This would again have to be met by the government.  Also, if universal health coverage is fulfilled, people including the uninsured would be using the healthcare system indiscriminately.  Employers and the segments of the population that currently have insurance would be considering avoiding payment of premiums.  This would result in additional costs for the government.  Hence, there would be a raise in the costs of healthcare if Universal healthcare coverage was implemented (Chua).

Part B: Answer each of the following questions in one to three sentences. Each answer is worth four points.

1. You work in the hospitals health information management department. Part of your job is to assist the medical residents with completing records and documentation. One of the residents complains that he doesnt understand why insure companies need so much documentation and the reimbursement system is so complex. How do you respond?

            Insurance companies require detailed documentation to justify and validate all medical claims.  Even if certain treatment is conducted and if no documentation has been done, reimbursement would not be provided.  The medical diagnosis has to be confirmed, the need for treatment should be established, and all bills and statement of accounts need to be produced as proof of expenditure on medical treatment.

2. Mary was receiving Medicaid in Texas. When she moves to California, can Mary assume that shell receive the same coverage there?
Medicaid is a healthcare funding system that is partially met by the Federal government and majority of the costs are met by the state.  As various states have various policies towards Medicaid, the benefits are not automatically transferred when the individual moves from one state to another.  For an individual to continue receiving benefits under Medicaid, he/she needs to cancel the previous benefits and apply for new benefits.

3. Compare point-of-service (POS) plans with health maintenance organization (HMO) plans.

            In the HMO plan, medical treatment is provided following payment of a amount or premium (prepayment), without giving consideration to the quantity of Medicare which is actually required.  The HMO network consisting of physicians and hospitals would provide the HMO services.  On the other hand, in the POS plan, the beneficiary would be paying a premium and would be using the facilities under the primary healthcare provider within the network.  If the individual uses the healthcare provider outside the network, service would be provided at a discounted rate (based on the PPO services).

4. Youre an inpatient coder in a hospital. Youve just coded a Medicare Part A record with a diagnosis-related group (DRG) reimbursement of $12,000. You notice in the hospitals computer billing system that the patients charges are $19,500. Thats $7,500 more than the hospital will be reimbursed. How does the difference between the charges and the DRG reimbursement become resolved?

            The policies of the hospital play an important role in determining the means by which such a situation would be resolved.  The hospital would accept the Medicare payments that have been met for claims, and deduct those segments that need to be borne by the patient.  In case any shortage still occurs, it would be usually written off as paid (within certain limits).

5. You work in a physicians office performing billing. You notice that guidelines havent been followed accurately in completing the claim form. What will happen if you dont correct the claim form?

            If the gridlines have not been met accurately whilst filling up the claim form, there are all chances that the claim would get rejected.  Bills have to be made for the procedure or services again.  The physician would also not receive any fees for the services he/she has provided.  The personnel Incharge of billing can also resubmit a fresh claim with corrections.  In case, he/she is unable to correct it, the amount would have to be written off by the physician’s office.

http://www.agencyinfo.net/iv/medical/types/hmo-ppo-pos.htm

6. Why did the Centers for Medicare and Medicaid Services (CMS) implement the National Correct Coding Initiative in 1996?

            The national Correct Coding Initiative was introduced by the CMS in the year 1996 to ensure that a control mechanism exists to prevent incorrect coding for healthcare services (leading to improper payment under Medicare or Medicaid).  The National Correct Coding Initiative also tries to develop appropriate coding systems, ensures better coding methods and ensures that all problems related to coding are appropriately addressed.

http://www.oig.hhs.gov/oei/reports/oei-03-02-00770.pdf

7. List some of the risk areas that can be identified through the auditing process.

Misappropriation regarding use of funds
Trying to fraudulently overcome tax liabilities
Any deficiency in the insurance claims
Identifying thefts by the employees
Determining any loss in the inventory or resources
Determining the need for hospital stay and discharge status
The preciseness of the DRG coding

8. Youre an HMO director. You would like to ensure that your managed care plan is meeting industry standards. Whats one way that you can do this?

            An important part of ensuring that a managed care plan is meeting the industrial standards prescribed would be to implement a program to determine the ability of the plan to meet the needs of the patients and further ensure that the plan is able to improve the quality standards.

9. You work for a third-party payer performing medical records review. Your job is to match codes that were submitted on the claim to documentation in medical record. You notice that a code has been input for a colonoscopy procedure, but you dont see the procedure report anywhere in the record. As the third-party payer representative, what will your action be regarding the code that was submitted on the claim form?

            The medical records can be sent to a review panel for further evaluation.  The review panel can insert the procedure on their discretion, sent it back to the hospital for further information or reject the procedure.

http://www.ama-assn.org/ama/no-index/physician-resources/3882.shtml

10. Youre reviewing reimbursement for a Medicare surgical craniotomy case. The case falls into DRG 1, which has a relative weight of 3.0970 and a geometric mean length of stay of 6.3. The hospitals current standard reimbursement rate is $1500. Calculate the DRG reimbursement for this case.

            3.0970 (relative weight) * $ 1500 (the standard reimbursement rate) = $ 4,645.50.

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