Provider Reimbursement In Health Care

Obtaining reimbursement for services provided is a necessity for the survival of many health care organizations. This paper will explain, in my opinion, why the Centers for Medicare and Medicaid Services (CMS) are involved in this development and how it affects the American public. I will offer a suggestion to ensure meeting policy and procedure. I will finish by discussing three ideas listed on the CMS website.

When Medicare was first established, Medicare adopted the payment methods of Blue Cross Blue Shield which meant that the program was paid hospitals on the basis of their own costs and physicians were being reimbursed by the fees that they charged which caused hospitals and physicians to provide care without boundaries (Anderson et al., 2015). This method caused Medicare to dissipate the budget that was established for beneficiaries to utilize. Now, with the ACA being implemented, Medicare had done an overhaul of payment reimbursement. Medicare is now moving toward a volume to value payment initiative that links payment to patient outcomes, experience of care, while giving providers an incentive to limit spending

The American human services framework is experiencing a rapid shift that incorporated a movement from fee-for-service payment into value-based payment that rely profoundly upon the provider integration plus care coordination (Santo, 2014). Value- based installment attempt to realign the economic incentive regarding care delivery by integrating doctors pay to value and quality. The FCA and AKS, are regulatory structures that were basically created to handle fraud and abuse claims emerging from the fee- for-service reimbursement framework.

Health care in the United States (U.S.) is driven by a makeshift of services and financing. Americans access health care services in diverse ways, from private doctors’ offices, to hospitals, and to insurance providers. The effects of the ACA will have numerous changes impacting hospitals and physicians practices. One of the main goals of healthcare reform is to reduce Medicare expenses by combining payment for services provided by hospitals, doctors, and nursing homes into one lump sum, which will effect

Quality and financial viability being closely tied is an extremely salient point. Furthermore, the Affordable Care Act has influenced the requirement for high-quality, cost-effective care provision by implementing Value Based Purchasing (Aroh, Colella, Douglas, & Eddings, 2015). In addition, there are presently Centers for Medicare and Medicaid (CMS) quality indicators that effect reimbursement for hospitals (Xu, Burgess Jr, Cabral, Soria-Saucedo, & Kazis, 2015). For example, if a facility does not meet the indicator threshold for catheter associated urinary tract infections, central line infections and/or pressure ulcers their reimbursement is affected. Given that the quality of care provided by a hospital is

Historically, reimbursement has been Fee-For-Service (FFS): tied to volume of visits, hospitalizations, procedures, and tests. This reimbursement structure creates misaligned incentives and fragmented, suboptimal patient care resulting in burgeoning costs and a lack of focus on outcomes. As a result, CMS and the industry have been

The Patient Protection and Affordability Act (ACA) was enacted by President Barack Obama’s Administration on March of 2010. The ACA was designed to generate healthcare reform, and is actually the most comprehensive law affecting managed care legislation since Medicare and Medicaid were enacted in 1965 by President Lyndon Baines Johnson (Kongstvedt, 2013). One of the main reasons for the creation of the ACA has been to contain out of control healthcare costs in the U.S. by transforming the manner in which hospitals are paid for surgeries (Chow, 2013). The new role that government will play in the healthcare sector will undoubtedly effect current healthcare practices.

There is a constant change and upgrade in technology that is being used not only in the Healthcare setting but in everything we have and everywhere we go. Since healthcare is a big business, the healthcare fraud and abuse is becoming a national issue. We should be aware of it in order to avoid such abuses and fraud.

Centers for Medicare and Medicaid Services (CMS) had adopted the “no-pay” rule in the year 2008 with the objective to encourage hospitals to terminate medical complications (American Medical News, 2012; Stone, et.al., 2010). Under this rule, CMS denies the payment to the healthcare facilities for any extra cost which is involved in treating Medicare patient. This policy has the significant impact on the health care system as the hospital executives need to redefine their priorities and enhance their efforts towards improving patient care.

According to the United State’s Centers for Disease Control report in 2003, 86% of Americans over 65 have one cardiovascular disease, arthritis, asthma, cancer, chronic pulmonary disease or diabetes and the cost for treatment of these will create a drain on an already taxed health care insurance agency (Implications for Health….Workers, 2003). Although the government has attempted to curb the cost of health care with The Tax Equinity and Fiscal Responsibility Act, The Prospective Payment System, HMOs and DRGs they were not able to demonstrate a high rate of return that has been associated with bundling of payments, pay-for-performance and shared savings programs (Williams & Torrens, 2010). In addition, as the population ages and requires additional services, the need to adjust physician reimbursement model will have to accommodate the new trend. In the 1990, physician services reached a high of 23 percent of Medicare spending and in 1992 Medicare initiated a resource based relative-value scale were implemented to adjust for geographic cost/price variations but CMS is now moving toward pay-for-performance to link the patients overall healthcare to outcomes (Williams & Torrens,

Medicare proposed revisions to payment policies in regards to the Physician Fee Schedule while focusing on primary care, chronic care management, mental health and diabetes. The recently proposed rule regarding physician fee schedules aims to improve payment, payment systems, and payment policies, as well as coordinates accountable care organizations’ quality measures with the current Medicare reimbursement rules, specifically, the Quality Payment Program and Medicare Access and CHIP Reauthorization Act, which rewards quality of care rather than the volume of care. CMS is updating payments to better reflect the changing healthcare community and value a service provides by increasing the amount of quality measures. Furthermore, in order to

Many healthcare organizations are driven by profit. Their primary goal is to ensure that their business is profitable. Patients are seen as numbers instead of human beings. Depending on their health coverage, they often encounter discrimination because of lower reimbursement rates. Some physicians refuse to take Medicaid and other government funded programs due to their fee schedule. Facilities and physician offices prefer commercial payers because they receive larger reimbursements which generate more revenue for the business. Even in the emergency room, if you have limited or no insurance, you are given minimal treatment, stabilized, and discharged to go home or even transferred to a different facility for continuous care. We witness

Over the past five years, federal and state budgets have been shrinking, and decreasing federal funding has resulted in reimbursement cuts for the industry surpassing profitability. Healthcare reform expanded access to insurance for some industry patients, but many states chose not to expand access to federal healthcare. Adding to the changes, other provisions of the recent healthcare legislation, the Centers for Medicare

United States Health Care Reimbursement and Health Care Quality CMS Attempt at Improving Health Care Quality Traditionally, healthcare has been based on a volume status, or how many patients a single healthcare provider can see. This overload of patient to healthcare provider has caused a decline of the quality of care patients are receiving. The United States government recognized this and wanted to move to a better system of healthcare, one that is based on quality instead of volume.

The positive outcomes that have resulted due to value base programs have caused the model to gain traction and ignite one of the largest changes in history in the health care marketplace. By linking reimbursements to service quality, insurers such as the Centers for Medicare and Medicaid Services have facilitated a massive leap forward in the performance of United States health care providers. This achievement is a considerable accomplishment in the face of an institution that has received reimbursement from insurers via a fee-for-service model during the last 75 years. Soon, valued based payment models will represent the norm as more insurers support initiatives such as shared savings program, integrated clinical care, and accountable care payment models.