HITT217 Health Insurance And Reimbursement

Question: Submit a draft of the Federal and State Payment Systems portion of your research and analysis. Be sure to address all critical elements as listed below. Specifically, the following critical elements must be addressed: III. Federal and State Payment Systems: a) Federal and State Regulations: Considering the recent changes in economic policy at the federal and state levels, what changes in federal and state regulations present the most concern for healthcare leaders? Be sure to provide support for your response. b) Reporting Requirements: Analyze the reporting guidelines required by Medicaid and Medicare and other government payment systems. What are the opportunities and challenges for healthcare leaders in meeting reporting requirements? c) Compliance Standards and Financial Principles: Analyze how healthcare organizations in general utilize financial principles to ensure compliance with government standards. d) Government Payer Types: Considering Medicaid, Medicare, and other government payer systems, what strategies would you recommend organizations implement in order to receive full reimbursement on claims as well as to improve timeliness of this reimbursement? Be sure to justify your recommendations. Answer: Federal And State Regulations: The Present Changes In Economic Policy The Congressional Budget Act of 1974, an economic policy that provides regulations and procedures to the Congress changes yearly.The change is made in entitlement, discretionary spending, social welfare programs, and the tax code. It is built on discretionary spending, andfunds are renewed each year (Larrat, Rita & Vogenbeg, 2012). The Pay as You Go Rule is a law that demands a mandatory increase in spending on entitlement and social welfare programs such as the Medicare. The policy is offset by a reduction in spending and increased taxation (Larrat, Rita & Vogenbeg, 2012). Concern For Healthcare Leaders. Healthcare leaders need to be cognizant of regulations set by the judicial branch and Congress. The changes in economic policy can change the structure of healthcare organizations,reimbursement of stakeholders, the role of a practitioner and it turns apatient’s treatment(Larrat, Rita & Vogenbeg, 2012). The extent in which healthcare providers support patient care activities in accordance to the aims of the Affordable Care Act will determine the success in avoiding legal and regulatory dilemmas, which involve reimbursements and standards of clinical practice. Furthermore, the Affordable Care Act promotes an increase in the oversight of fraud and abuse. The ACAwill continue tightening the legal, regulatory constraints on health leaders while it exposes stakeholders outside the system (Teel, 2018). Reporting Requirements The Medicare-Medicaid Plan (MMP) should occasionally submit performance and monitoring data to various states. Furthermore, it should document any refusals or outreach attempts. MMP can report a member as unreachable after three outreach attempts. In addition to that, the three efforts should specifically target completion of the care plan (Centers for Medicare and Medic-aid Services, 2018). Appeals and grievances related to benefits which are supplemental should be reported, grievances are included in the personal care or home health category.MMPs need to haveentire membershipirrespective of whether the member is enrolled through the opt-in enrollment or a passive admission. Nevertheless, Medicaid members should not be included, and the MMPs need to add members registered in the last day of the period of reporting. The 90 day of admission is equivalent to three calendar months (Centers for Medicare and Medic-aid Services, 2018). Opportunities And Challenges For Healthcare Leaders. Regulatory requirements increase the cost of providing services and care. Healthcare leaders are overwhelmed by the new reporting requirements and changes that regulate Medicaid and Medicare eligible healthcare providers. Furthermore, healthcare leaders are burdened with new standards. The provider needs to engage in information sharing and awareness regularly to update staff and other stakeholders. Healthcare leaders must do compliance training on reporting requirements, routine audits and address non-conformity issues that arise due to in compliance with reporting guidelines (Teel, 2018). Quality and performance reporting system can be effective enough in affecting the level of reimbursement. The Physician Quality Reporting System (PQRS) is a quality reporting program to encourage individual eligible professionals as well as group practices to report the data and information related to the quality of care to the Medicare. The last program year for PQRS was 2016. Under the quality payment program, PQRS transitioned to the incentive payment system on the basis of merit. It is basically reporting on the quality and performance of the healthcare professionals (CMC.gov Centers for Medicare & Medicaid Services, 2018). However, various challenges might come for the healthcare leaders in meeting the reported requirement as most of the times it will go over their heads or they might feel it problematic. Some of the times they might find it difficult to encounter with. But, multiple opportunities are there behind most of the obstacles as the challenges will be helpful to step back and take a big picture. It will be helpful in enhancing the population health. Simultaneously, it is effective in shifting from volume to value-based reimbursement. This will integrate the system and help in infection control. Reimbursement rate difference is also possible in this way. Financial Principles And Compliance Standards. According to the compliance principle, healthcare organizations(HCOs) will adhere to applicable laws, standards, and regulations. Providers and facilitiesneed to adhere to rules that govern privacy and confidentiality about patients and treatment they receive. Furthermore, healthcare organizationsuse billing compliance and coded data in payment of health care providers and to prevent anoccurrence of fraud. Therefore, activities conducted by a healthcare organization can be deemed ethical and lawful (UC San Diego, 2018). Healthcare is a highly regulated industry and non-compliance to health regulation can even end a healthcare organization in a law suit. Healthcare organizations generally utilize financial principles in order to ensure the compliance with the government structure. It follows specific pay structures that discourage the presence of favoritism between the patients and the doctors. It can be achieved by fixed incentive paycheques. This smart and effective financial move can be helpful in preventing the corruption as well as multiple medical malpractice. The Health Information Technology for Economic and Clinical Health (HITECH) Act is very much helpful in order to promote the adoption as well as meaningful use of health information technology and at the same time, it can also be a very good choice to increase the revenue of the healthcare organization. It was signed into the law on 17th February of 2009, and it effectively addresses the security as well as the privacy concerns associated with electronic transmission of the health information of patients. Genuinely, when the security of health information will be ensured it will increase the productivity which will positively impact the whole revenue cycle of the healthcare organization as a result. It will be effective in increasing the revenue of the healthcare organization (HHS.gov Health Information Privacy, n.d). The availability principle ensures the availability of information promptly, efficient retrieval and accurate information. The trust of the organization is diminished when data is not easily retrieved (UC San Diego, 2018) Financial reporting compliance dictates that healthcare organizations should give transactions that follow generally accepted accounting principles. Sources of funds and the use of funds must be combined with the type of activity and by following restrictions regarding the application. Revenue collected is reported when earned; expenditures recorded when services are received (Galin, 2018). Government payer types. The role of payer and providers is to ensure that the limited financial resources are being used appropriately in order to create a good quality of services by the healthcare organizations. Medicare is administered by CMS and Medicaid is a joint initiative between federal and state government. Medicare and Medicaid will be the payer primarily. Healthcare organization should reduce inefficiency in the management of revenue to keep pace with changes in reimbursement. HCOsshould focus on managing revenues differently, so that value to patients is appropriately paid regarding accuracy ortimeliness. Furthermore, organizations should understand how management of claims affects reimbursement so that they can ensure claims are paid (Murphy, 2018). Organizations that succeed in reimbursements combine each component of the patient-provider interaction and ensure it fits into the cycle of revenue. Furthermore, the organizations address how the interactions can introduce gaps which can lead to risk or a loss (Murphy, 2018). Improving reimbursements starts with an assessment of the current operating environment which has three functional areas; technical, operational and financial. The financial area examines the receivable accounts, collection rates and denial management. The different side deals with systems applications, and processes. The operational side focuses on staffing, workflows and vendor relationships. Technology improves claims management and the rates of reimbursements. References. Centers for Medicare and Medic-aid Services. (2018, July 13). Medicare-Medicaid Plan(MMP) Reporting Requirements. Retrieved October 31, 2018, from CMS.gov: https://gov/Medicare-Medicaid- Coordination/Medicare-and-Medicaid-Coordination/Medicare-MedicaidCoordination-Office/FinancialAlignmentInitiative/MMPInformationalandGuidance/MMPReportingRequirements.html. CMC.gov Centers for Medicare & Medicaid Services. (2018, April 26). Physician Quality Reporting System. Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html Galin, D. H. (2018). Evaluating the Information Governance Principles for Healthcare: Compliance and Availablity. Retrieved October 31, 2018, from HIM Body of Knowledge: https://www.bok.ahima.org/docoid-107667 HHS.gov Health Information Privacy.(n.d). HITECH Act Enforcement Interim Final Rule. Retrieved from https://www.hhs.gov/hipaa/for-professionals/special-topics/hitech-act-enforcement-interim-final-rule/index.html Larrat, P. R. (2012, April). Impact of Federal and State Legal Trends in Healthcare services. Pharmacy and Therapeutics, 37(4), 218-220. Murphy, K. (2018). Key ways to Improve Claims Management and Reimbursement in Healthcare Revenue Cycle. Retrieved October 31, 2018, from RevCycle Intelligence: https://revcycleintelligence.com/feature/Key-ways-to-Improve-Claims Mnagement-and-Reimbursement-in-Healthcare-Rev Teel, P. (2018, February 13). Five top challenges are affecting healthcare leaders in the future. Retrieved October 31, 2018, from Hospital Review.: https://www.beckershospitalreview.com/hospital-management-administration/five-top-challenges-affecting-healthcare-leaders-in-future.html UC San Diego. (2018, June 8). Administrative Responsibilities: Principles of Regulatory Compliance. Retrieved October 31, 2018, from Blink: https://blink.ucsd.edu/finance/accountability/admin-responsibilities/compliance.html

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