Medical Billing Recommendations for CARE4U Medical Practice
CARE4U Medical Practice is the newest office serving patients in the San Antonio Northwest area. Dr. Wells and Dr. Ness are committed to providing the utmost quality of care based on the patient-centered medical home (PCMH) model. With the transition to value-based care, the PCMH model upholds value by “increased patient-centered care access, the use of team-based care strategies, population health management, personal care management and support, care coordination, and continuous quality improvement” (Bresnick, 2016). Even though the quality of care provided by PCMH physicians has resulted in fewer emergency room visits, unwarranted hospitalizations, and increased patient satisfaction
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In today’s changing environment of health care delivery, providers may be faced with many challenges. One of these challenges is the decision to outsource or keep in house medical billing. Alternative payment models are a key factor in evaluating how a practice should conduct billing. Fee for service is shifting to risk-based models to include capitation, bundled payments and shared savings arrangements (Alternative Payment Models, n.d). There are companies that are prepared to deal with alternative payment models. These include Care Coordination, Bundled Payments for Care Improvement Conveners, ACO Enablement, and Clinical Intelligence supplies (Fengler & Roth, 2015). The purpose of this paper is to provide a recommendation for the decision to outsource medical billing or develop an in house department by examining advantages and disadvantages for both …show more content…
Keeping billing in house will employees. A member of the practice will need to be responsible for managing the staff unless a medical billing manger will be hired. Acquiring computers and other equipment along with sophisticated software will also require someone to handle it. If the practice is expected to grow, a good infrastructure needs to be in place in order to minimize growing pains. If the focus of the practice is to be medicine, then someone will need to be hired to run the business side. Advantages of outsourcing medical billing encompass many aspects from staffing choices to hardware and software technology. The first advantage of outsourcing is the cost savings related to staffing. If an in house staff is to be hired, than the following must be considered, amount of staff, salary, benefits, taxes, and cost of training (Medical Billing, n.d.).Outsourcing eliminates the need for all expenses related to upkeep of medical billing
Furthermore, uncertainty of new reimbursement models, diminishing reimbursement, and complicated compliance regulations are playing the role of a catalyst for streamlining the Chargemaster process in majority of healthcare organizations. A good example of these challenges was prompted by the Center for Medicare and Medicaid with the release of data and chargemasters from several healthcare facilities. The release of the chargemasters sends a wave shock across the healthcare industry as it depicts a huge price discrepancies among health care providers, and due to this exposure many healthcare organizations attempt to rectify their charges. The main purpose the CMS release the chargemasters was to encourage transparency in hospital’s billing
Health Care workers are constantly faced with legal and ethical issues every day during the course of their work. It is important that the health care workers have a clear understanding of these legal and ethical issues that they will face (1). In the case study analysed key legal and ethical issues arise during the initial decision-making of the incident, when the second ambulance crew arrived, throughout the treatment and during the transfer of patient to the hospital. The ethical issues in this case can be described as what the paramedic believes is the right thing to do for the patient and the legal issues control what the law describes that the paramedic should do in this situation (2, 3). It is therefore important that paramedics also
Outsourcing simply means acquiring services from an external organization instead of using internal resources (Butler, 2000). By using outsourced resources, organizations can gain a competitive advantage by utilizing contingent staff to accomplish strategic goals without incurring the fixed overhead. By focusing on the leading edge and highly specialized skill sets, outsourcing providers can often offer higher quality services, or at a lower price than the client organization. Typical reasons for outsourcing go beyond simple contingent staffing. Outsourcing providers are able to maintain economies of scale with regard to specialization (...
A recent phenomenon in the health services is the burgeoning of outpatient healthcare centers. Particularly vigorous growth has been observed in centers that perform diagnostic tests and simple surgeries and procedures like colonoscopies. At the current state, outpatient care centers outnumber hospitals in Pennsylvania. Furthermore, these centers now perform one of every four surgical and diagnostic procedures in the state (Levy 2006). However, the trend applies nationwide, and other states could easily follow suit. Many critics have commented on the negative and positive aspects of this trend. What remains to be determined are the long term effects (on health and the economy) of this paradigm shift, in terms of the wellness of the community as well as economically. Proponents of the movement have pointed to the lower overhead for these clinics trickling down to lower costs for patients. However, critics skeptically question whether the real benefits are for the patients or simply as a mechanism to stuff physicians' wallets. When considered as firms in the marketplace, it is evident that these two groups, both servicing the health needs of the community, have vastly different balance sheets and income statements. This transfers over to a difference in operational functionality, profitability, and cost structure. Furthermore, the disparity of financial motivations that is visible in the varying profit margins is of concern to the community. All of these are important considerations to be made when considering the economic implications of this new phenomenon.
Historically, case management came to fruition as an answer to the shift of cost-based reimbursements to prospective payment models, assisting hospitals in keeping costs low regardless of the quality of care. However, as health care reform became effective, case management has grown into a newer role in assisting in the delivery of patient-centered quality care. Typically, case managers must be self
As our health care system continues to evolve and become more focused on a preventive and coordinated approach to patient care, we too must progress and create programs that follow such principles. The Patient-Centered Medical Home (PCMH) model follows similar ideologies and recently has gained increasing support. The patient’s primary care physician, who will provide preventive and continuing care for the patient, directs this medical model. The PCMH model of care is comprised of a health care team working together to serve their patient and provide quality care.1 The model works to empower the patient by promoting communication with not only the physician but with the nursing staff, specialists, and other health care providers. Every patient
A multispecialty group practice is one that consists of individual physicians who offer various medical and specialty services in that practice by contracting to a managed care plan. Managed Care Organizations are formed by insurance companies that either own a provider network or create one by arranging with independent providers (Gapenski, 2009). The payment structure used to reimburse providers regardless of services provided falls into the category of either fee-for-service or capitation based. Fee-for-service is the reimbursement according to services provided, either through reimbursing based on the cost of services provided or reimbursing based on rate schedule of services provided. On the other hand, in the Capitation system, providers are paid a fixed amount depending on the number o...
...lthcare system is slowly shifting from volume to value based care for quality purposes. By allowing physicians to receive payments on value over volume, patients receive quality of care and overall healthcare costs are lowered. The patients’ healthcare experience will be measured in terms of quality instead of how many appointments a physician has. Also, Medicare and Medicaid reimbursements are prompting hospitals, physicians and other healthcare organizations to make the value shifts. In response to the evolving healthcare cost, ways to reduce health care cost will be examined. When we lead towards a patient centered system organized around what patients need, everyone has better outcomes. The patient is involved in their healthcare choices and more driven in the health care arena. A value based approach can help significantly in achieving patient-centered care.
The Medical Center of Plano has established itself as a leader in health care since its opening in 1975, nestled in Plano, Texas. Since its inception as a small community hospital, it prides its self of the delivery of quality health care as well as its concern for its patients. Over the years, it has grown to “a full-service facility, with 427-bed acute-care facility with more than 1,300 employees and over 1000 physicians on staff, representing over 70 specialties and subspecialties.” (The Medical Center of Plano, 2014, para. 2) The main campus “includes the main hospital and medical offices, also includes an outpatient surgery center, a comprehensive cancer-treatment center, an emergency and Level 2 trauma center, a radiology/imaging center, a comprehensive cardiovascular program, the Center of Lifestyle Enhancement, The Bariatric Institute, Wound Care Center and complete woman’s and children’s services including a high-risk antepartum unit and a Level 3 neonatal intensive care unit.” (The Medical Center of Plano, 2014, para. 2)This success can be accredited to their Mission Statement:
Medical billing transforms health care services into billing claims. The responsibility of the biller is to follow that claim to ensure the physicians, hospitals, third party billing companies, as well as federal and state governments receive reimbursement for the work that is provided. An experienced biller can boost revenue performance for the facility while keeping the business running smoothly.
The concept of Health Insurance and managed health care the inventions of the twentieth century that were started as prepaid health care. The early insurance concept was merely a way for people to pay medical bills not a way of protecting individual financial assets as the case is today. Overall the health care industry has endured significant changes since its inception.
Given the fact that one-third of all healthcare expenditures is for ambulatory care, it is safe to say that patients spend most of their time in an ambulatory care setting (Carper, 2013). This setting has a significant impact in the overall assessment of the healthcare industry and how care is delivered. It is important to address data collected by surveys to implement strategies for quality improvement. Affecting care in Ambulatory settings will have the largest significance in the health outlook.
The majority of a patient’s care remains within the system, enabling maximum efficiency and coordination. Furthermore, research has shown that ACOS help reduce medical errors, eliminate duplicate services and facilities as well as provide financial incentives to demonstrate high-quality, patient centered care (Richman, Schulman, 2011). Several ACOs across the country are showing an increase in care coordination leads to a reduction in no-shows, improved medication adherence and enhances preventative and chronic care. For example, in a care coordination pilot performed by Trinity Clinic, which is part of an ACO, care coordinators boosted quality and revenue by reducing their no show rate form 4.5% to 2.8% primarily due to a previsit phone call set up by the coordinators (Mullins, Mooney, & Fowler, 2013). ACOS are not the entire solution, but these organizations are certainly a step in the right direction, putting patient satisfaction and quality as part of their fundamental
Fee-For-Service (FFS) is a payment model where services are unbundled and paid for separately. In health care, it gives an incentive for physicians to provide more treatments because payment is dependent on the quantity of care, rather than quality of care. Similarly, when patients are shielded from paying cost sharing by health insurance coverage, they are incentivized to welcome any medical service that might do some good. FFS is the dominant physician payment method in the United States, it raises costs, discourages the efficiencies of integrated care, and a variety of reform efforts have been attempted, recommended, or initiated to reduce its influence.
Patient-centric care practices are becoming the foundation of the current healthcare system. However, there is work and research to be done before a fully integrated and patient-centric system is in place throughout the healthcare system. Murphy (2011) has taken a closer look at the patient-centric care system, and what must be done before the patient truly becomes the center of the healthcare universe. Patient-centric care makes the patient and their family members a significant part of the care team, which may help to remove unneeded and unwanted services (Murphy, 2011). Murphy (2011) determines four areas within the healthcare system that can be improved to increase patient involvement in their care: eHealth, primary care, hospital care, and health information exchange.