Finance in healthcare is a very important part of the health care industry. The primary role is to plan for, obtain, and make use of resources to increase the productivity and value of the business (Nowicki 2007). Income revenue for the healthcare industry mainly stems from insurance providers or third-party payers. Third-party health insurers seek reimbursement for services rendered by a provider, through the prospective payment systems, either through a fee for service cost or capitation cost. Health insurers use medical coding in order to unify reimbursement to the providers for services performed. Some of the the third-party health insurers are the government insurance program and the private health insurance plans. Third-party health insurers are insurance companies, either public or private. Public insureres like Medicare and Medicaid is insurance that is available to individuals that are unable to work due to a disability, individuals that are disadvantaged such as low-income, and the elderly over the age of 65. Medicare and Medicaid is provided and paid for by the government. Private insurers are insurance companies that …show more content…
There many different medical codes such as the International Classification of Diseases (ICD) codes, the Current Procedural Terminology (CPT) codes, and the Healthcare Common Procedure Coding System (HCPCS). ICD codes are the most widely used codes for designating diseases and injuries and are currently a 10 digit numerical code. CPT codes are used to specifically identify medical treatments. HCPCS codes are used to expand CPT codes for nonphysician services and medical equipment. Is is very important for medical coding to be accurate in order for providers to be reimbursed for the proper services provided. This coded information is also used in projecting future services needed which assists providers and isurers to prepare for future
ICD-10 CM is developed by Centers for Medicare and Medicaid Services (CMS) involved with the Department of health and human Services (HHS) known as inpatient procedural coding system.includes several new features and offers a greater specificity.Is classified by 5 to 7 characters.Carries laterality,and allows an additional code when there is a x which symbolizes an expansion to allow the code add a seventh character as many times, this includes injuries,external causes and obstetrics.
For instance, as (Adamopoulos, 2014), the ICD-10 implementation delay has resulted in many providers either slowing down or suspending their efforts to prepare for the transition. The author also outlines four actions to consider are “optimize the revenue cycle”, “develop a clinical documentation improvement program”, “ensure integration with physicians”, and “look at the transition overall as more than an IT project”, (Adamopoulos, 2014). Geisinger had already well-established contingency plans for payers unprepared for the conversion. A wide-range of potential issues can arise such as health information management (HIM) with coding resources with
This combines medicine-based detail and the level of detail to provide more accurate information for following and recording of health care and public health, quality of care issues, and health results. The advanced number of codes will not necessarily make it more difficult to use. The increase in codes should make it easier for health care providers to find the correct code.” ICD-10 codes are very different from ICD-9 codes and have a completely different structure.” (International Classification of Diseases, 2015). ICD-9-CM codes are mainly number-based and have 3 to 5 digits. ICD-10 codes are alphanumeric and contain 3 to 7 characters. ICD-10 codes are more specific and descriptive with "one-to-many" matches in many events. There are nearly 5 times (68,000) as many (identification of a disease or problem, or its cause) codes in ICD-10-CM than in ICD-9-CM (13,000). This is nearly 19 times as many procedure codes in ICD-10-PCS than in ICD-9-CM. Like ICD-9-CM codes, ICD-10-CM/PCS codes will be updated every year via the ICD-10-CM/PCS Coordination and Maintenance Committee (International Classification of Diseases,
Healthcare professionals associated with medical billing and coding know the progress the technology has made so far. In the last few decades, medical billing and coding has switched from being a paper-based system to a computerized format. Under HIPAA laws, medical practitioners had to develop new software in order to send out electronic bills. With the advent of electronic medical records (EMR), with one touch of a button, doctors, Nurse Practitioners and PAs can gain access to all the care a patient has ever received from every healthcare facility the patients visited previously and can figure out possible illnesses. This enables statistical documentation of the population as a whole as well. EMR can also make the healthcare system more transparent and allow integration with reimbursement data. As the healthcare system changes, this will prevent unnecessary costs and make it easier to get the reimbursements needed to treat a patient.
“Current Procedural Terminology codes otherwise known as CPT codes are a classification of diagnostic and therapeutic procedures performed by physicians and other health care providers”. Each procedure is assigned a 5 digit code (Centers for Disease Control and Prevention, 2013). “CPT codes are numbers assigned to every procedure and service a medical professional may provide to a patient. These include medical, surgical and diagnostic services” ("5 thoroughly explain," 2014). They are then used by insurers to determine the amount of reimbursement a physician will receive from the insurer. Since everyone uses the same codes to mean the same thing, they ensure uniformity ("5 thoroughly explain," 2014).
Varying in size, these companies act as a middleman between the patient and the medical facility finance office. All having slight variations, the abundance of insurers can cause confusion and often times incorrect billing. Insurance companies unlike individuals are able to negotiate a discounted payment with the hospital, but at a steep price. Of the considerable amount of money the United States put into the health industry, 35% of it went to paying for administration cost of both the insurer and the hospital (Brill,Steven, pg.34-43, Time). It should be no surprise then that the United States leads the world in every category of health care cost, often times charging twice more than the second most expensive country.
Most people do not make enough income to afford healthcare services short of the help of third party payers. Third party payers supply the bulk of medical payments. There are three parties involved in Physician and hospital reimbursement: the patient, the provider, and the insurance company that compensates the providers on behalf of the patient. Third party payers can be very competitive and the terms can either be simple or complex when it involves contract negotiations between physicians, hospitals. Physicians and hospitals should be familiar with negotiations, terms, and payment schedules.
Today healthcare cost is constantly rising. It is important to ensure that patient 's health are maintained and supported outside the clinical settings such as their homes and communities. Healthcare organizations play an important role in serving people to provide an effective health care and improve the patients ' outcome. They focus on activities and strategies to provide a high quality care for many communities. This is their way of helping people and their community healthy. Organizations have a way of improving the patient 's outcome through monitoring of patients especially those who have high medical needs.
To comprehend our current health care system, it is important to understand the history and how health care has evolved in the United States. The healthcare system we have now didn't always exist. Believe it or not, before 1920, most people would not of known what health care coverage meant! So how did the United States turn into one of the few developed countries lacking nationwide healthcare? Understanding U.S. healthcare history will help you understand the dynamics that built the system that, we struggle with today. Furthermore, I will make conclusions on the current problems we are facing.
Case 1 -- You work in a busy multi-specialty clinic with a high patient volume. The physicians enter the type of code that will yield the greatest reimbursement. You suspect the codes are not accurate.
This paper presents an interpretation of payment reimbursement systems in the health care industry. Managed care is a health care delivery system that is organized to manage quality and cost utilization. A comparative overview and description of payment compensation will be given in order to understand the flow of finances in the health care industry. The focus will be on the capitation and fee-for-service reimbursement systems. Readers will then be able to conclude that the appropriate reimbursement method is reliant on upon the amount of risk a party is able to assume.
American health care, a debate that has been ongoing for at least the last century. Health insurance is provided by private insurance companies through subscription-like plans and provided by government in the form of Medicaid and Medicare. Medicaid is for eligible low-income individuals and Medicare is for senior and disabled citizens. Many questions surface such as “is it a human right?” and “Should it be for free?”
Health Care Costs, Access, and Quality The United States has a highly developed health care system that can be extremely complex and infuriating, but it has come a long way considering that most health care facilities were just a place where the sick were housed and cared for until their death in the pre-era’s. However, health care today is at the crossroads of continuous struggles with providing health care to all Americans while maintaining standards of quality at a cost that is affordable to individuals and the nation as whole (Shi, Singh, 76). There are multiple reasons as to why the cost of health care keeps rising.
...ue to numerous medical errors. With the amount of medical errors that currently do occur which is a current health care issue it cost the health care billions of dollar each year to fix the mistakes that were made.
Health care has always been an interesting topic all over the world. Voltaire once said, “The art of medicine consists of amusing the patient while nature cures the disease.” It may seem like health care that nothing gets accomplished in different health care systems, but ultimately many trying to cures diseases and improve health care systems.