introduction to Health information

HTH 2304, Introduction to Health Information Management 1

Course Learning Outcomes for Unit VIII Upon completion of this unit, students should be able to:

6. Discuss the use of current technology and systems to ensure the integrity of the medical record and an optimum health information system for appropriate users and requestors. 6.1 Discuss the use of current technology and how it has evolved for health information

management.

Course/Unit Learning Outcomes

Learning Activity

6.1

Unit Lesson Chapter 10 Article: “Back Office Relief: Automating the Arcane World of Device Warranties” Unit VIII PowerPoint Presentation

Reading Assignment Chapter 10: Introduction to Coding and Reimbursement Additional Reading Assignment: In order to access the following resource, please click the link below. Kacik, A. (2017). Back office relief: Automating the arcane world of device warranties. Modern Healthcare,

47(31), 16. Retrieved from https://libraryresources.columbiasouthern.edu/login?url=https://search- proquest- com.libraryresources.columbiasouthern.edu/healthcomplete/docview/1925495200/AB94CC8C67B04 D08PQ/2?accountid=33337

Unit Lesson Coding Medical coding is an essential practice and management function for medical providers and healthcare payers because it drives how medical services and products are reimbursed. The job description for a medical coder outlines that the employee must assign numeric and alphanumeric codes for medical diagnoses and procedures. When hired as a medical coder, the hired individual must have been properly trained and have taken an oath to follow rules and regulations (Bowie & Green, 2016). Medical coders assign specific ICD (International Classification of Diseases) codes to medical diagnoses and procedures for in-patient cases and medical diagnoses for outpatient cases. Medical coders also assign CPT HCPCS level II (national) codes to procedures and services for outpatient cases. Without the assignment of these codes, healthcare entities cannot submit billing claims to medical insurance companies. In order to generate correct billing information to submit to medical insurance companies for reimbursement, healthcare providers ensure that their billing and coding staff are kept informed about coding updates (Bowie & Green, 2016).

UNIT VIII STUDY GUIDE

Health Information and Current Technology

HTH 2304, Introduction to Health Information Management 2

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Types of Healthcare Reimbursement Payments In the current healthcare delivery system, there are a number of major payment and reimbursement systems used by most healthcare providers. Healthcare providers design systems to reimburse providers based on the type of medical services and products provided to patients. Let’s review some of the major reimbursement systems used by physicians and hospitals. Types of Physician Payment Types of physician payments are listed below:

 Fee for services: This is a specific amount paid to the physician for the service that he or she has rendered. For example, if a physician sees 30 patients a day and each person plays $100, then the total amount paid to the physician is $3000.00.

 Per case and per capita: This is the amount paid to the physician for each type of care treated. Per case payment is not used since there can be a wide variety of services depending on the diagnosis and treatment.

 Salary payment: This is the incentive for physicians who are paid a salary based on the incentives for a fee for service payment. Most physicians do not receive incentives.

 Observation: A physician practice profile shows that under fee-for-service, the physician has the incentive to generate more services, especially if the fee exceeds the marginal cost of the service. By comparison, the physician will not have such an incentive under capitation (Shi & Singh, 2012).

Hospital Payment Hospital payments in the past were paid on a retrospective basis. In other words, a third party insurer would pay the hospital for the expenses that have already been charged. Since then, there have been new retrospective payment variations. These types of payments can sometimes lead to higher quality and costs. There has been a new avenue of payments that is setting the basis of payment before the period of payment. This can cause issues with the cost since there can be financial risk for both the hospital and payer. For example, if a person is admitted to the hospital, the longer the individual is in the hospital, the more money the hospital will be paid. The cost will be higher for the patient, and the hospital will be paid for the time. This is usually a per diem cost such as $200 per day. They have been cases in which an individual will pay the same amount based on the treatment that is being completed. This can reduce some of the amount the payer spends. There is also a flat per-case payment system, which are outliers and typical cases. Usually, typical cases are charged a flat fee but the outlier maybe charged more or less depending on the condition. Managed Care Managed care includes two major types of medical insurance plans as discussed below: Health-maintenance organizations (HMOs) are licensed and funded health plans that place some of the providers, as well as the health plan, at risk for incurred medical expenses. HMOs utilize primary care physicians as gatekeepers with a focus on quality and finance. For the most part, consumers must use the contracted or network physicians for their health care. Going outside of the network typically results in the patient paying some, if not all, of the services that would have been covered had the patient selected in- network care. Consumer advocates and consumers themselves consider an HMO as a mechanism used by payers to control utilization of medical services and to ration medical care (Hicks, 2014). Preferred-provider organizations (PPOs) typically provide consumers with the ability to select any provider that they like within the provider and facility network (Shi & Singh, 2012). They can select in-network providers and take advantage of the discounts negotiated by their insurance plan, or they can receive care by providers that are not part of the network. So what is the catch? When consumers use the participating network providers, the insurance covers more of the charges or, perhaps, a larger percentage of the charges. In most cases, PPOs cover 90% of the total bill and the other 10% is covered by patients. For example, if you were seen by an in-network physician and the bill totaled $100.00, your financial responsibility is about $10. On the other hand, if a patient opts to use out-of-network medical providers or facilities, they may end up paying a larger portion of the changes incurred. Often patients are responsible for 40% to 60% of total charges.

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The Impact of Healthcare Legislation The U.S. healthcare delivery system has many components including hospitals, physician services, academic integrated health delivery systems, medical equipment companies, health insurers, managed care plans, and the pharmaceutical industry. Another fact that you should know about the U.S. healthcare industry is that it is a highly regulated and mandated industry. Think about this for a moment: Almost every aspect of the healthcare delivery system is overseen by a regulatory body and sometimes, by several local, state, and federal agencies. It is no wonder that many healthcare professionals and medical providers feel that they spend more time complying with rules than actually doing the work itself and providing the clinical care services patients need. There are quite a few landmark healthcare legislations about which we need to know. Let’s review some of the major healthcare legislations that have made huge impacts on the U.S. healthcare delivery system. The Medicare Act of 1964 The Medicare Act of 1964 is a complex and vast insurance program. Therefore, in order to understand the impact of Medicare, we must understand the millions of men, women, and children who receive insurance coverage under this program. Since 1964, Medicare has provided coverage primarily to the senior citizens of the United States. Medicare also covers other medical concerns that are not age related, such as end stage renal disease (ESRD). The impact of Medicare is significant. Senior citizens are living longer, they are healthier, and they certainly want the best that medicine and technology can provide. They are also looking for funding from the same wallet used for Medicare (Barton, 2010). The Affordable Care Act of 2010 The Affordable Care Act of 2010 (ACA) focuses on having individuals purchase health insurance (Shi & Singh, 2012). In this situation, all individuals must buy insurance coverage in order to ensure population healthcare needs are addressed. Under the ACA, most individuals would be required to maintain insurance for a minimum essential premium. The ACA uses healthcare exchanges to allow healthcare consumers to shop and select the best healthcare coverage plan that meets their needs (Shi & Singh, 2012). Through the ACA, individuals may apply for insurance online, by phone, with in-person help, through an agent or broker, or even by mail. The ACA website also offers guidance on selecting a health insurance plan and what to do if your situation changes due to a new baby or a job change (HealthCare.gov, n.d.). For more information about the ACA, check out the website at the link below. HealthCare.gov. (n.d.). Home page. Retrieved from https://www.healthcare.gov/. The Future of the United States Healthcare Industry The U.S. healthcare delivery system is under pressure as a result of constant changes due to government reforms, consumer expectations, and emerging new delivery models such as Accountable Care Organizations (ACOs) and reimbursement payment system such as pay-for-performance (P4P) (Shi & Singh, 2012). Also, changing technology and social and demographic factors are making significant impacts (Hicks, 2014). As a result of these significant changes and trends, healthcare reforms are expected to continue to be introduced to the healthcare delivery system. The desired goal of these healthcare reforms is to address quality, access, and affordability concerns that impact the healthcare competitive market. Under the presidency of Barack Obama, the Affordable Care Act took place. Some individuals were pleased with the change, and some individuals were not. However, one of President Trump’s stated missions is to change the healthcare plan that has been put into place. More changes will occur in the healthcare industry to come. This is due to the medical changes that are taking place continually and new technology resources on the rise. This will only continue to grow in time.

HTH 2304, Introduction to Health Information Management 4

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References Barton, P. L. (2010). Understanding the U.S. health services system (4th ed.). Chicago, IL: Health

Administration Press. Bowie, M. J., & Green, M. A. (2016). Essentials of health information management: Principles and practices

(3rd ed.). Boston, MA: Cengage Learning. HealthCare.gov. (n.d.). 5 ways to apply for health insurance. Retrieved from

https://www.healthcare.gov/apply-and-enroll/how-to-apply/ Hicks, L. (2014). Economics of health and medical care (6th ed.). Burlington, MA: Jones & Bartlett Learning. Shi, L., & Singh, D. A. (2012). Delivering health care in America: A systems approach (5th ed.). Sudbury, MA:

Jones & Bartlett.

Suggested Reading Please click the links below to access the PowerPoint presentations, which accompany the textbook reading assignments. Click here for the Chapter 10 PowerPoint presentation. Click here for the PDF version.