Final project

Federal and State Payment Systems

Maria Williams

Southern New Hampshire University

10/18/2020

Federal and State Payment Systems

The healthcare reform changes in who can provide certain services and which healthcare organizations can cross state lines, and the methods and levels of reimbursement for products and services present concerns in many aspects of leadership in healthcare. For example, Medicare bundled payments for all services from three days before a patient’s hospital admission to thirty days after discharge. Centers for Medicare and Medicaid Services (CMS) came up with regulatory initiatives to address never events, which in this case mean preventable medical errors that should not occur in a hospital. Such implementation brings about concerns of having a negative financial impact on healthcare institutions through the reductions in prescription reimbursements, restrictions on admissions to long-term care facilities and cuts for numerous ancillary services and programs make for a challenging business climate for the healthcare industry (Larrat et. al., 2012).

Besides, federal budget-cutting has affected the healthcare system overall. The goal is to save more by decreasing healthcare spending over the next decade, with nearly all of the savings accrued from Medicare and Medicaid reductions (Larrat et. al., 2012). It also affected other health-related agencies and programs such as the many federally funded health programs, the public health infrastructure and the Food and Drug Administration (FDA). This brings concern to healthcare leadership in that the beneficiaries will experience fewer covered services, higher copayments and premiums, and reduced access to healthcare professionals. It can also alter the way healthcare organizations are structured, how individual stakeholders are reimbursed, how the role of practitioners might change and how patients are treated.

The challenge faced by healthcare leaders in meeting reporting requirements includes; Healthcare regulatory challenges. Medicaid, Medicare and other government payment systems are required to regularly submit monitoring and performance data to CMS and participating states by providing documents with guidance, technical specifications and applicable codes for the core and state-specific measures. These drive up the cost of providing services and care. Leaders also face the challenge of countering the frustration and confusion from people who have formed a sense of security with their current coverage. Medicare and Medicaid and other government payment systems are overwhelmed by new changes in regulation and new reporting requirements in the sense that they are usually burdened to comply with a variety of newly revised standards including the Accountability Act (HIPAA), CMS and Health Insurance Portability (Teel, 2018).

However, healthcare leaders can find the opportunity to meet reporting requirements by developing and accessing issues to create the best approach and delivery system that meets the needs of their staff and patients. Currently, there is a noticeable gap between the belief that change is necessary and actual support for specific reform plans designed to achieve that change (Teel, 2018). This enables them to actively engage in awareness and information sharing and implement document control programs to address non-conformance incidents immediately utilizing integrated healthcare platforms.

Healthcare organizations in general utilize financial principles to ensure compliance with government standards by putting efforts to ensure that compliance strategies are embedded in all aspects of operations and that organizational culture reflects the commitment to ethical behavior at all times. This can be achieved by, for example, maintaining financial information in a manner that ensures timely, accurate and efficient retrieval. Besides, billing compliance can be useful in substantiating the payment of providers for healthcare services and avoid allegations of possible fraud or abuse (Datskovsky et. al., 2015). Lastly, these organizations can also utilize the financial principle by putting reimbursement programs in place to ensure that care is provided in conformance with applicable laws and regulations by having an effective compliance and ethics program.

The strategies I would recommend for organizations to implement in order to receive full reimbursement on claims as well as to improve the timeliness of reimbursement include; Understanding how the different components of claims management affect reimbursement by these organizations. Depending on the size of the healthcare organization and extent of processes surveyed, hospitals and physician practices can have the means to create a remediation roadmap as well as benchmarks to improve performance. When the various parts of the revenue cycle is in tune with an organization, the reimbursements flow predictably. It will contribute to making sure that the claims cycle is managed effectively.