Journal 8

Healthcare is an important and vital priority for most countries. However, healthcare leaders face complex and tough challenges derived from current pressures such as the growing occurrence of chronic disease, ageing population, and changes in state and federal regulations.

One significant change in state and federal regulations that present the most concern to healthcare leaders is the 2017 tax reform. The new reform will create new possibilities for healthcare facilities that want to convert their tax savings into strategic advantages and also present challenges to other organizations. Simultaneously, Emergent trade forces may also generate uncertainties for healthcare organizations (Siwicki, 2019). Healthcare leaders must, therefore, find it important to reorganise their operations to accommodate the new tax rules, discover what operational modifications the tax reform requires, evaluate how refunds and taxes could impact their Medical Loss Ratios, reorganise their supply chain to accommodate the emergent trade uncertainties and new tax system, among other related actions.

The changes in the Affordable Care Act also present a concern to healthcare leaders. Two years into Trump regime, the ACA remains a law, however, the administration and the Republican policymakers have redesigned sections of it through regulatory, legislative, legal, and budgetary actions. These actions might create new losers and winners. Healthy citizens and small entities looking for inexpensive premium will benefit, as well as insurance companies selling short-term insurance. Those who will not benefit from these decisions and policies are the payers and providers dependant on individuals covered by ACA or Medicaid plans residing in old-fashioned states which are more sceptical of the law.

Reporting Requirements

The Physician Quality Reporting System (PQRS) was established in 2006 to facilitate high-quality in healthcare systems. PQRS was a voluntary reporting system that offered financial incentives for certain health care professional who participated in Medicaid and Medicare to submit a report on specific quality measures to the Centers for Medicare and Medicaid Services (cms.gov). By reporting, healthcare providers would assess how frequently they were meeting a certain quality metric. Using the feedbacks provided, they would also compare their performance with their peers.

PQRS ended in 2016 and gave rise to the Merit-based Incentive Payment Systems (MIPS). MIPS combines Physician Reporting System (PQRS), Medicare Electronic Health Record (HER, and Value-Based Payment Modifier (VM). With MIPS, eligible providers can participate as a group or individual. An individual qualified provider is required to report MIPS data to CMS under an NPI number which is tangled to a distinct TIN. On the other hand, two or more qualified providers can take part in MIPS as a group and will be evaluated as a group (aafp.org). With MIPS, providers will not face penalties every year and there will be greater certainty in yearly payment updates. However, MIPS lacks measures relating to consumer engagement.

Compliance Standards and Financial Principles

Financial proficient is a major factor in today’s ever-changing and unpredictable healthcare environment. Uncertain and volatile environment factors have forced healthcare leaders to look for ways to become more financially competent. Healthcare leaders are now discovering the need to utilize financial principles in everyday financial and accounting practices. The purpose is to ensure conformity with government standards.

Healthcare organizations always ensure they disclose all the necessary and relevant information about the company so that the individuals who rely on that information can make a correct and sound decision about those companies. They also ensure that financial and accounting calculations are consistent from one financial period to the other. Healthcare organization also try as much as they can to be unbiased to ensure that the users of their financial statement interpret the information with credibility. Besides that, they also match all their expenses with the revenues to ensure profitability is summarized accurately.

Government Payer Types

Healthcare providers are usually paid by government payers or insurance through a reimbursement system. The amount paid is normally based on the service provided and the agreed amount that the Medicaid, Medicare or any other health insurer has agreed to pay. However, in today’s healthcare industry, Medicare and Medicaid reimbursement with errors are so common and organizations may fail to receive full and timely payment. To avoid this, organizations can use the following strategies:

· Stay up to date with Medicaid, Medicare standards, and any other payer. This will enable organizations to avoid being denied full reimbursement because of ignorance.

· Complete forms legibly, accurately, and appropriately. This will lessen agony at the end.

· Review claims before it is sent to the payer to check for errors and make necessary edits (Bean, 2017). Edits should be customized because every payer has different formatting preferences and requirements for claim forms.

· Train billing staff on how to collect all essential patient information and how to fill claim forms correctly.

· Train physicians and nurses on how to properly document properly and how to choose diagnostic codes and procedures. Proper documentation will lessen coding errors.

· Hold frequent meetings with clinicians, billers, and front office to discuss coding and billing issues. Frequent communication between the back and front office will prevent repeated errors.

References