Wait a second!
More handpicked essays just for you.
More handpicked essays just for you.
Health information management chapter 6
Health information management chapter 6
Health information management chapter 6
Don’t take our word for it - see why 10 million students trust us with their essay needs.
Recommended: Health information management chapter 6
HIM 6840 Case Studies in Health Information Management Name: Bayo Oshunlalu Case #: Case 2-6 Case Title: Chargemaster Maintenance What is a Chargemaster? The chargemaster or charge description master (CDM) is a basically a financial tool or an electronic system that housed detailed description/information about services charged to patients. The chargemaster can be a manual list or a file that is located in the organization’s account receivable billing system that contains hospital’s service items, and their charges. Furthermore, the chargemaster is a very crucial aspect of the reimbursement cycle and must contain vital information necessary to produce an itemized statement and claim form. Key components of the chargemaster include chargemaster …show more content…
Furthermore, uncertainty of new reimbursement models, diminishing reimbursement, and complicated compliance regulations are playing the role of a catalyst for streamlining the Chargemaster process in majority of healthcare organizations. A good example of these challenges was prompted by the Center for Medicare and Medicaid with the release of data and chargemasters from several healthcare facilities. The release of the chargemasters sends a wave shock across the healthcare industry as it depicts a huge price discrepancies among health care providers, and due to this exposure many healthcare organizations attempt to rectify their charges. The main purpose the CMS release the chargemasters was to encourage transparency in hospital’s billing …show more content…
The hospital’s departments lack involvement in the chargemaster process. Lack of effective communication channel to handle issues with chargemaster. Non-existence educational program about the importance of chargemaster maintenance. Inadequate workflow model to ensure ease of chargemaster maintenance. Propose Process Improvement for Chargemaster. The first step to enforcing an appropriate chargemaster and to avoid all ramification associated with the status quo is to establish a position for chargemaster coordinator, and to create a chargemaster master department to facilitate the effective handing of our organization chargemaster. In addition to establishing chargemaster position and department, a chargemaster committee should be created that consist of all major departmental leadership. The duties of the chargemaster committee will involve developing a standardized form for handling charge related issues, and establishing a communication platform that will enable all departments to collaborate on chargemaster related issues. Furthermore, the chargemaster committee will also be responsible for creating a policies and procedures manual that will be used to reference information about the issue concerning
With the passage of the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) has initiated reimbursement based off of patient satisfaction scores (Murphy, 2014). In fact, “CMS plans to base 30% of hospitals ' scores under the value-based purchasing initiative on patient responses to the Hospital Consumer Assessment of Healthcare Providers and Systems survey, or HCAHPS, which measures patient satisfaction” (Daly, 2011, p. 30). Consequently, a hospital’s HCAHPS score could influence 1% of a Medicare’s hospital reimbursement, which could cost between $500,000 and $850,000, depending on the organization (Murphy, 2014).
Conversely the OPPS (outpatient prospective payment system) is controlled for different service groups such as the APCs (ambulatory payment classifications). The outpatient services in the various APCs are the same in terms of the required resources and clinical aspects. The payment rate for APC for each group is adjusted to justify the geographic differences and is applied to all of the services in this group. The health care institutions adopt a fixed amount for all the outpatient service based on the classifications of the ambulatory services. Marcinko (2006) notes that Medicare uses it to reimburse the health care providers for the items and serves which are not part of the prospective payment systems. A MPFS (Medicare physician fee schedule) determines the rate of payments for therapy and physician services based on conversion factors, relative value units, as well as, the indices costs.
The chargemaster or charge description master (CDM) is a basically a financial tool or an electronic system that housed detailed description/information about service charges to patients. The chargemaster can be a manual list or a file that is located in the organization’s account receivable billing system that contains hospital’s services, item, and their charges. Furthermore, the chargemaster is a very crucial aspect of the reimbursement cycle and must contain vital information necessary to produce an itemized statement and claim form. Key components of the chargemaster include, chargemaster line-item numbers, line-item descriptions, revenue codes, CPT codes or healthcare common procedure coding system (HCPCS) codes,
A certified medical biller is one who passes the Certified Medical Reimbursement Specialist Exam and because of the certification, they are greatly sought after. Medical billing presents the chance for a well-organized, task-oriented individual to use her eye for specificity in a crucial role within the health care industry. A biller with a good sense of self-concept can communicate effectively because they are confident in themselves, they can accurately rea...
Fontenot, S. (2013). Understanding the Affordable Care Act Bit by Bit: Will Transparency and Sunshine Shrink Costs?. Physician Executive, 39(5), 86-91.
There are several factors that contribute to the complexity of the revenue cycle. Frequent changes in contracts with payers, legislative mandates, and managed care are just a few examples of reasons why revenue cycle in the healthcare industry is so complex. Furthermore, the problems that arise in the steps of the revenue cycle further complicate the whole process. For example, going through the steps of the revenue cycle efficiently is extremely difficult when it is managed by poorly trained personnel. Furthermore, if a healthcare provider does not have the proper information system to track patient records and billing, receiving reimbursement can become difficult. In addition, one of the main factors that delay payments is denial from the insurance companies. The reason for Denial includes incorrect coding, the certain sequence of care and medical necessity or even delay in submitting claims. Lastly, inefficient patient correspondence can not only hinder the process of revenue cycle but also result in many patient complaints (Wolper, 2004).
All things considered, it is clear that commercial bundled payment arrangements are not immune to laws related to Fraud and Abuse issues. Civil Money Penalty, Stark Law, and Anti-Kickback Statutes are identified as the most important federal laws to consider. While all of them impose a critical penalty to health providers if violated, each law has several exceptions that are applicable and favorable in commercial bundled payment context. Therefore, like I hypothesized in the beginning, active utilization of such exceptions will minimize legal and compliance risk so that health providers can avoid the issue of Fraud and Abuse. I highly recommend everyone who designs a commercial bundled payment program to keep in mind the laws and regulations discussed above as they present challenges in creating and implementing a compliant program.
Medicare uses the Medicare Physician Fee Schedule to pay physicians and the Outpatient Prospective Payment System to pay hospitals and other outpatient facilities. Recently, the Centers for Medicaid and Medicare Services (CMS) made changes to physician and outpatient payments. The five levels clinic visit codes or five outpatient codes were replaced with a single code. “The Chronic Care Management Fee will go into effect in January 2014 and will be the new form of physician compensation. Bundle Payment is a way for paying for high volume, high cost hospital procedures. Global payment enables providers to reduce unnecessary care and bring down spending under control but creates incentives for providers to restrain the supply of services.
The newly appointed district sales manager, Larry Barr, faces the problem of allocating sales quotas among his various sales representatives. This decision will affect everyone's earnings including his own. This problem is compounded by the fact that different territories have, for a variety of reasons, different potentials. In addition, the territory that is known to be the toughest will soon require a new sales rep.
There are three data sets that are the minimal amount to support this system. These data sets include: 1) patient-reported outcomes data, 2) social determinants of health data, and 3) activity-based costing data that will allow accurate management of financial margins in per-capita reimbursement contracts (“Population Health Management”). These data sets are the minimal requirements and without them, the organization will never achieve value-based care. If an organization does have these data sets, they are able to provide better patient outcomes for an efficient cost. Before a healthcare organization can apply care management applications, it always needs to consider the cost of care that will result to the
When a payer needs to reimburse a provider, there are two categories in which reimbursement can be done, fee-for-service (FFS) and capitation. Both the cost-based reimbursement model and the prospective payment model belong to the fee-for-service category where the payment made is linked with the total amount of services that are provided. In cost-based reimbursements, the costs paid by the payer are directly related to the supplying of healthcare services. The payer must agree to reimburse the provider by paying for all allowable costs that “incurred during the providing of services”.1 An example of cost-based reimbursement is Medicare, the version used for hospital payments back in between the years of 1966 and 1983. All in all, cost-based
With the Affordable Healthcare Act taking effect this year, it is putting the consumer in control of their healthcare options. Insurance companies and doctors must now meet the mandates of this new act and still provide the quality care that patients need and demand. Moving patient records into the cloud will aid in lowering the costs to the individual doctor’s offices. Intense cost-management pressures result from the increasing demand for services as
If an affordable care organization (ACO) adopts risk-based payment contracts it is likely to achieve success in its endeavors as it brings accountability and monetary motivation for physicians to change their best practices and improve quality to reduce healthcare spending. In other words they may garner cost savings and decrease the spending through reducing emergency room visits and hospital admissions. There is a considerable reduction in the costs of care. It can help in making healthcare
According to a recent article published by Inside Arm, balance billing is "the process by which patients receive higher-than-expected bills from healthcare providers, often due to having unknowingly received out-of-network care---has become a bellwether in state capitols across the U.S."
Another important factor in profitability is the ability to retain customers. If patients are dissatisfied, they may choose to seek healthcare from a competing organization. If a pattern of customer dissatisfaction is systemic the consequences can be significant revenue losses. Multiple studies indicate patient dissatisfaction is related with failure to return to a healthcare provider (Zoller, Lackland & Silverstein 2001). A three year study at the Medical University of South Carolina concluded that a 10 percent decrease in mean patient satisfaction scores would predict as many as 250 patients that would not return for subsequent healthcare needs. At a rate of 3.4 visits per patient, the overall loss would equate to approximately 850 lost visits per year (Zoller et al., 2001). These lost visits would result in a financial impact as much as a 1.5 million dollar loss per year according to statistics from Kaiser State Health Facts (Rappleye, 2015). Thus far the principles of customer satisfaction discussed here hold true in nearly every business sector. In the healthcare market, however, there is another substantial reason to ensure patients have a satisfactory experience. Specifically, Medicare payments made to hospitals are directly affected by customer satisfaction scores. As part of the Affordable Care Act, an initiative was introduced by the federal government