Reimbursement Methodologies free essay sample

The Blue Cross plan has been evolving since 1929 and the Blue Shield since 1939. 3. Explain why the lack of universal health care coverage can raise health care costs. Many studies have show that people without health insurance do not get the health care they need. The sicker they become, the more tests, surgeries, and other health care services they need. This scenario increases costs to the health care industry. If public health is improved, then the population becomes healthier and health care costs should decrease. A good initiative to move toward a healthy population is the Healthy People 2010 program. 1. You work in the hospital’s health information management department. Part of your job is to assist the medical residents with completing records documentation. One of the residents complains that he doesn’t understand why insurance companies need so much documentation and the reimbursement system is so complex. How do you respond. In order to serve the patient and help to provide quality care, it is important to have a complete and accurate medical record. We will write a custom essay sample on Reimbursement Methodologies or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page Keeping records complete and accurate will help in figuring out reimbursement costs and discovering what costs are covered. It is also very important to keep track of all services and supplies so that the hospital can be reimbursed. 2. Mary was receiving Medicaid in Texas. When she moves to California, can Mary assume that she’ll receive the same coverage there? Medicaid policies on eligibility services and payments are complex and very considerably from state to state. Thus, Mary may not be eligible in California even though she was in Texas. 3. Compare point-of-service (POS) plans with health maintenance organization(HMO) plans. In an HMO plan, the insured must choose a primary care physician and then must obtain a referral to seek care from a specialty physician. In a POS plan the insured chooses a primary care physician but still has the option of receiving care from other physicians without the need for a referral. POS combines the features with thos of the PPO. 4. You’re an inpatient coder in a hospital. You’ve just coded a Medicare Part A record with a diagnosis-related group (DRG) reimbursement of $12,000. You notice in the hospital’s computer billing system that the patient’s charges are $19,500. That’s $7,500 more than the hospital will be reimbursed. How does the difference between the charges and the DRG reimbursement become resolved? In some cases, the DRG payment received by the hospital may be lower than the actual cost of providing Medicare Part A inpatient services. In these cases, the hospital must absorb the loss. 5. You work in a physician’s office performing billing. You notice that guidelines haven’t been followed accurately in completing the claim form. What will happen if you don’t correct the claim form? It is important to follow payer guidelines when completing a claim form; otherwise, reimbursement will be delayed until the form is corrected. 6. Why did the Centers for Medicare and Medicaid Services (CMS) implement the National Correct Coding Initiative in 1996? CMS implemented the National Correct Coding Initiative (NCCI) in 1996 to develop correct coding methodologies to improve the appropriate payment of Medicare Part B claims. 7. List some of the risk areas that can be identified through the auditing process. Some of the risk areas found through the auditing process are, DRG coding accuracy, variations in case mix, discharge status (transfers versus discharges), services provided under arrangement, medical necessity, evaluation and management services, charge master description and three day payment window are a few. . You’re an HMO director. You would like to ensure that your managed care plan is meeting industry standards. What’s one way that you can do this? One way to ensure a managed care plan is meeting industry standards is to involve HEDIS (Health Plan Employer Data and Information Set) through the National Committee for Quality Assurance. 9. You work for a third-party payer performing medical records review. Your j ob is to match codes that were submitted on the claim to documentation in the medical record.