Finance Management & Reimbursement Methodologies

Finance Management & Reimbursement Methodologies
732.2.1: Reimbursement Methodologies – The graduate describes and compares contemporary healthcare reimbursement methodologies and systems utilized in the United States.
732.2.3: Voluntary Healthcare Insurance Plans and Managed Care -The graduate describes key components of private, commercial, and Blue Cross and Blue Shield insurance plans and evaluates how various insurers use coding in the billing process.
732.2.4: Government-Sponsored Healthcare Programs—Including Medicare and Medicaid – The graduate evaluates and explains various government-sponsored healthcare programs and recognizes the impact that government-sponsored healthcare programs have on the healthcare system in the United States.
732.2.5: Government-Sponsored Healthcare Programs—Other Components and Methods – The graduate evaluates and explains components and methods of non-Medicare/non-Medicaid government-sponsored healthcare programs; and recognizes the impact that government-sponsored healthcare programs have on the healthcare system in the United States.
732.2.6: Ambulatory Reimbursement Systems – The graduate evaluates and explains the structures and components of and performs payment calculations for outpatient healthcare reimbursement in healthcare
The healthcare reimbursement system in the United States is complex. The health informatics professional needs an understanding of the basic principles of the third-party payer system and the many options that are available to citizens through government-funded healthcare programs. Private and commercial insurance companies and Blue Cross and Blue Shield plans offer a different menu of options to their clients. One issue is certain: All third-party payers are interested in decreasing healthcare costs while improving quality and controlling access to unneeded services.
This task will allow you to examine the complexity of the healthcare reimbursement systems and begin to compare the similarities and differences between them. To complete this task, read the attached “A Lifetime of Healthcare Services,” which is a case scenario about a woman named Sophie. Then create a multimedia presentation, diagram, table, or other illustration comparing the differences and similarities among the various insurance options and reimbursement systems that were used to pay for Sophie’s medical care throughout her lifetime.
You are explaining these reimbursement systems from the perspective of a billing department manager training two new staff members. You believe that if you can explain these systems with a real patient, it will be easier for your new staff to understand the various requirements of these reimbursement systems.
A. Compare Sophie’s health insurance options for each of the five phases of her life.
1. Recommend the health insurance option that would provide the best coverage to meet Sophie’s needs during each phase.
a. List the elements of each plan you recommended.
b. Discuss the reimbursement requirements of each plan you recommended.
c. Discuss restrictions to each plan you recommended.
B. If you use sources, include all in-text citations and references in APA format.
Attachment: A lifetime of Healthcare Services
A Lifetime of Healthcare Services
Phase 1
When Sophie was first married, her husband worked in a meat packing plant. His job
offered an optional health insurance package that could cover Sophie’s husband, Sophie,
and their family. Sophie did not have a job; she stayed home to care for their five children
and an elderly parent. Many years passed. Sophie and her husband raised their children,
and her elderly parent died. Sophie’s husband looked forward to retirement.
Phase 2
Sophie’s husband died before he reached retirement age. His company offered his benefits
plan to Sophie, which she could enroll in indefinitely if she chose to do so. This plan would
include good drug benefits. The insurance plan through the company had become a
managed care plan over the years. Sophie decided to remain with her husband’s insurance
Phase 3
Sophie turned 65. She was on a tight budget and did not like the idea of paying a monthly
premium. However, she wanted her insurance to provide many physician and service
options. She also wanted a good drug coverage plan.
Phase 4
Sophie’s health declined. She was hospitalized for several days after a fall and received
home healthcare for several weeks. She was diagnosed with Alzheimer’s disease about a
year later and could no longer safely live alone. Sophie moved into an assisted living facility,
and her daughter took over the financial management of her assets. In addition to other
financial obligations, Sophie needed to pay for the cost of rent for the facility.
Phase 5
As Sophie’s Alzheimer’s disease progressed, she needed more nursing care than was
available at the assisted living facility. Sophie’s doctor recommended a skilled nursing
facility for her continued care. At the nursing facility, she received nursing care, help with
activities of daily living, and recreational therapy. This facility, too, required a rent payment.
Sophie was transferred to the skilled nursing facility from her previous assisted living
facility. After the first year, all of Sophie’s financial resources were exhausted.
Textbooks used in this course to use as sources
Essentials of health care finance / William O. Cleverley, James O. Cleverley, Paula H.Song.—7th ed.
Professional Review Guide for the RHIA and RHIT Examinations 2010 Edition, Patricia J. Schnering, RHIA, CCS
Competency 732.2.2: Clinical Coding and Coding Compliance – The graduate identifies and evaluates code sets associated with various levels of healthcare settings and articulates procedural and ethical guidelines, rules, and regulations for clinical coding within healthcare organizations.
Competency 732.2.7: Coding, Billing, and Revenue Cycle Processes – The graduate evaluates coding and billing functions and ascertains potential impacts to institutional revenue cycles for healthcare organizations.
Health informatics professionals working closely with the revenue cycle must address quality at every level of the cycle. A thorough understanding of how the coding function impacts steps along the continuum of the cycle will help decrease the risk of errors. Awareness of the work of quality improvement organizations and attention to recovery audit initiatives helps to build a culture of compliance.
In this task, you will describe various components of the coding and billing continuum and how errors may delay reimbursement or result in concerns of fraudulent practice. You will be required to discuss how several specific government directives have impacted healthcare organizations.
A. Evaluate the importance of the following government initiatives as they pertain to the coding function:
1. Medicare and Medicaid Patient and Program Protection Act of 1987
2. Operation Restore Trust
3. Medicare Integrity Program
4. Medicare Prescription Drug Improvement and Modernization Act of 2003: Recovery Demonstration Project
B. Explain the role of a quality improvement organization contracting under the Centers for Medicare and Medicaid Services as it applies to the coding process.
C. Diagram the activities of each step of the revenue cycle in the order in which they occur.
1. Describe the work of HIM staff members during each step of the revenue cycle in which they would be involved.
D. Illustrate how you would address the following automated billing report errors:
1. The date of service on one portion of the bill for a same-day surgery was not in agreement with the date on other portions of the bill
2. The diagnosis and procedural codes were inaccurate
3. A procedure was billed to the wrong patient
Textbooks used in this course to use as sources
Essentials of health care finance / William O. Cleverley, James O. Cleverley, Paula H.Song.—7th ed.
Professional Review Guide for the RHIA and RHIT Examinations 2010 Edition, Patricia J. Schnering, RHIA, CCS