Discussion

The payment determination form located in Chapter 7 provides an example of the various criteria that healthcare administrators must meet prior to submitting claims to Medicare for related programs. The example demonstrates that healthcare administrators work to develop processes and procedures for employees to ensure claims are completed properly and in a timely manner. With the many required criteria on these claim forms, properly completed, timely forms are often the focus of many healthcare administrators. Many administrators provide training on certification standards. In some cases, administrators will send employees for training on Medicare standards. When reviewing processes surrounding reimbursement, administrators will seek answers to the following questions:

· What control mechanisms are needed to ensure claim forms are filled out properly?

· What processes are needed to improve the timeliness of submissions?

· How will the organization keep track of outstanding claims?

· Who will be responsible for handling resubmissions?

Other Medicare-Medicaid reimbursement systems include those plans that relate to federally qualified health centers, rural clinics, and hospice services (Centers for Medicare & Medicaid Services [CMS], 2015). The underlying theme, despite the varying types of healthcare facilities and healthcare terminology, is how services are paid and which reimbursement system is applied. Healthcare administrators evaluate the financial performance and programs of the facility using various sources of data to examine how the practice is performing. This is done on an ongoing basis and especially during budget planning when estimating revenue on past performance. One source of data that measures revenue is an internal report generated to include an explanation of the Current Procedural Terminology (CPT) codes and the amount of revenue generated under each code.

CPT codes are used to describe the task and services a provider may provide for a patient. For example, there is a CPT code for an office visit, flu shot, vaccine, diagnostic, and stitching an open wound. There are numerous options that are used to identify the medical, surgical, or diagnostic care that can be performed for a patient. A projected revenue by CPT code report is used by resource administrators to determine the complexity of the patient office visit, the amount of time a physician spent with a patient, and the revenue generated by each code. Other data that are useful for projecting revenue are practice expenses, including, but not limited to, utilities, rent, labor, marketing, and supplies.

Medicare’s resource-based relative value scale payment system uses relative value units (RVU) to measure productivity relevant to CPT codes. Therefore, each CPT code has an RVU assigned that determines the compensation that will be charged for the varying levels of service. The physician’s work, costs associated with maintaining the practice, physician malpractice insurance, geographic practice cost indices (GPCI), and a conversion factor (specified by statute) is factored into the total (CMS, 2015). The conversion rate changes each year, similar to how the Internal Revenue Service (IRS) tax chart rates are updated each year.

In this module, you will examine the system of classifying health services for the various ways services are administered. Additionally, you will explore the differences between various facilities and how they are evaluated. In Module Eight, you will examine the models and policies of payment for post-acute care (PAC) facilities. At this point in the course, you should start to realize the importance of healthcare administrators as they navigate the various compliance and reporting requirements to ensure that their organization is being reimbursed appropriately for services that have been provided.

Reference:

Centers for Medicare & Medicaid Services (CMS). (2015). Ambulances Services Center. Retrieved from http://www.cms.gov/Center/Provider-Type/Ambulances-Services-Center.html