Final project submission

Compliance Standards and Reimbursement

Maria Williams

Southern New Hampshire University

03/27/2021

Compliance Standards and Reimbursement

While many healthcare providers and organizations do not intend to file false claims and commit fraud, complex processes and changing regulations make it almost impossible to avoid billing mistakes. For instance, healthcare providers must alter claims to satisfy specific requirements that do not comply with national standards. Thus, differing guidelines can result in false claims that can lead to financial and criminal implications. This paper explores different types of payment systems, reporting requirements, compliance standards, and types of government payers, as well as necessary measures to ensure timely reimbursement.

Federal and State Payment Systems

Today, federal and state authorities establish rules and regulations aimed at protecting the public, promoting access to care, and ensuring that medical practitioners adhere to high standards and are compensated for their services. Regulations are not only varied but also complex. Hence, it is important for healthcare management professionals to understand them and ensure that facilities comply with legal requirements. However, American Healthcare Act of 2017 presents significant challenges to healthcare leaders. According to Jost (2017), the American Healthcare Act of 2017 reduces the amount of additional funding that the Patient Protection and Affordable Care Act provides of 2010 to Medicaid. Enrollees can only receive coverage fee based on their category, which include elderly, children, expansion adults, and non-expansion adults, as well as blind and disabled.

Passage of the American Healthcare Act of 2017 is a matter of concern for healthcare leaders since it puts a cap on federal funding for Medicaid programs. In addition, states can only match a given amount of money and can only apply for additional funding if they comply with the Act’s compliance and need requirements. The move reduces insurers’ ability to cover many Americans, which hinders the ability to afford healthcare costs (Jost, 2017). Yet, Medicaid increases healthcare accessibility with more than 77 million people depending on Medicaid and Child Health Insurance Program (Medicaid.gov, 2021). Moreover, Medicaid aid funding is a significant source of support for various healthcare organizations such as nursing homes and hospitals.

Reporting Requirements

An understanding of reporting requirements Medicare and Medicaid Plan as well as other government payment systems is critical for maximum reimbursement. For Medicare-Medicaid Plans, it is important to report access including claims rejected during the first three months of enrolment and pharmacy point of sale claims rejected during passive enrollment. Medicare and Medicaid Plans must also report part C-sections, especially section VI and section VII. Section VI relates to rewards and incentive programs while section VII concerns payment to providers. Medicare and Medicaid Plans must also report part D sections covering sections II to V. Section II relates to medication therapy management programs, section III concerns grievances, section IV relates to improving drug utilization review controls, and section V concerns coverage determinations, redeterminations, as well as reopenings (CMS. gov, 2020). For healthcare leaders, these reporting requirements present significant challenges and opportunities. In particular, inaccurate filings may result in lower revenues and delays in reimbursements. Thus, they must put in place guidelines and policies that lead to accurate and complete reporting.

Compliance Standards

In healthcare, compliance with government standards requires attention to laws and regulations governing healthcare delivery and reimbursements. Due to the increasing complexity of healthcare operating environment healthcare leaders use financial principles to comply with government standards and regulations. For instance, healthcare providers have put in place internal control processes to ensure compliance with government standards. Healthcare leaders strive at fulfilling their responsibility to maintain internal control processes that ensure compliance with government standards by adopting and implementing corporate compliance plans. These plans contain policies and practices that foster compliance with applicable standards. Adoption of compliance plans help in reducing fraud, abuse, and wastages in healthcare organizations while simultaneously advancing the fundamental mission of providing quality patient care (Pascu, 2016). In addition to corporate compliance plans, healthcare organizations conduct internal audits to ensure compliance with legal requirements and regulations as well as to improve quality of patient care. Auditing is a process that can result in cost savings, avoid unnecessary redundancies, as well as improve patient satisfaction.

Types of Government Payers

A large percentage of payments for treatment costs from the government come from Medicare and Medicaid programs. Other programs include TRICARE, Children Health Insurance Programs, Indian Health Service, and Veterans Health Administration. Medicare is federally funded health insurance for persons aged 65 and above, disabled or suffering from stage IV chronic renal disease. Medicaid is federal and state funded health coverage for low-income persons and the disabled. TRICARE is coverage for military persons and their dependents, Veterans Health Administration is a program for veterans, and Indian Health Service is a program for Native Americans (James & Hughes, 2015).To ensure full reimbursement on claims healthcare leaders should eradicate inefficiencies in revenue cycle management. Singh, Durcikova, and Mathiassen (2021) indicate that healthcare organizations that succeed at reimbursement take into consideration how various aspects of patient-provider interactions affect revenue cycle. These areas include pre-service, process of care, process integrity services, billing services, and administrative services.

References

CMS. Gov.(2020). Medicare-Medicaid capitated financial alignment model reporting requirements. Washington, DC: Centers for Medicare & Medicaid Services.