Reimbursement Methodologies Discussion Week 5 Part 1: Discuss what a medical biller can do to make sure a WC claim is paid as rapidly as possible. WC stands for Worker's Compensation. Workers' Compensation is a type of protection giving pay substitution and health advantages to workers harmed over the span of work in return for compulsory surrender of the representative's entitlement to sue their boss for the tort of carelessness. This is a separate medical and disability reimbursement that proviedes coverage 100% when you have an job-related injury, illness, or conditions that arising during employment. Each State has there on rules and regulation when it comes to the employee to file for Worker's Compensation. The medical biller and coder …show more content…
Make sure the claims that you are submitting are the right code for the service provided. Part 2: Discuss the history of why HMOs were developed and if they met those goals as intended. HMO stands for Health Maintenance Organization. HMO “is a type of prepayment policy in which the organization bears the responsibility and financial risk of providing agreed-on healthcare services to the members enrolled in its plan, in exchange for a fixed monthly membership fee”. Retrieved from https://online.vitalsource.com/#/books/9781323108024 HMOs were designed–by Democrats and Republicans to dispose of individual medical coverage. Under an HMO course of action, individuals pay a set sum each month, and the HMO consents to give all their care or to pay for the secured mind that they can't give. The HMO enlists doctors and sets up clinics. The individual picks a particular supplier for his or her care called a primary care physician (PCP). Individuals agree to accept HMO coverage through their employer or through an individual arrangement. References United States Department of Labor. (2017). U.S. Department of Labor office of workers' compensation Programs. Retrieved from
United States Department of Labor. "U.S. Department of Labor - Wage and Hour Division - U.S. Department of Labor-General Information on the Fair Labor Standards Act (FLSA)." U.S. Department of Labor - Wage and Hour Division -
U.S. Department of Labor. U.S. Department of Labor, n.d. Web. The Web. The Web. 08 Feb. 2014.
Health Maintenance Organizations, or HMO’s, are a very important part of the American health care system. Also referred to as managed care programs, HMO's are combinations of doctors and insurance companies that are formed into one organization. This organization provides treatment to its members at fixed costs and decides on what treatment, if any, will be given based on the patient's or doctor's current health plan. Sometimes, no treatment is given at all. HMO's main concerns are to control costs and supposedly provide the best possible treatment to their patients. But it seems to the naked eye that instead their main goal is to get more people enrolled so that they can maintain or raise current premiums paid by consumers using their service. For HMO's, profit comes first- not patients' lives.
"Bureau of Labor Statistics Data." U.S. Bureau of Labor Statistics. U.S. Bureau of Labor Statistics, n.d. Web. 04 July 2017.
A managed care organization is a collection of clinics, doctors, hospitals, pharmacies and other healthcare providers who come together to offer health care to persons who are sign up for the services. In many cases, managed care organizations operate and are referred to as networks of health care providers. Managed care organizations are comprised of health care experts from different fields who come under an agreement to offer health care services to members. Once a member signs up, all their heath care needs are covered by the managed care organizations. Access to care outside the organization is restricted. Members under managed care organizations are usually assigned a primary care physician (PCP) who is the primary care giver for the member. The PCP is tasked with analyzing a member’s health problem before referring them to other sections of the managed care organization. Managed Care Organizations are usually well coordinated to meet the needs of members who have registered under their banner.
Managed care dominates health care in the United States. It is any health care delivery system that combines the functions of health insurance and the actual delivery of care, where costs and utilization of services are controlled by methods such as gatekeeping, case management, and utilization review. Different types of managed care plans came into development by three major factors. These factors include choice of providers, different ways of arranging the delivery of services, and payment and risk sharing. Types of managed care organizations include Health Maintenance Organizations (HMOs) which consist of five common models that differ according to how the HMO is related to the participating physicians, Preferred Provider Organizations (PPOs), Exclusive Provider Organizations (EPO), and Point of Service Plans (POS). `The information management system in a managed care organization is determined by the structure of the organization' (Peden,1998, p.90). The goal of a managed care system is to provide subscribers and dependants with needed health care services at the lowest possible cost. Certain managed care plans also focus on prevention by trying to keep members healthy.
ACOs are either Pioneers or a Medicare Shared Savings Program (MSSP). As the name implies, Pioneers were a small group of large organizations that adopted the ACO model early on. While 32 organizations signed onto the Pioneer program initially, only 12 remained in 2015. The Pioneer ACO Model was designed for organizations and providers already experienced in coordinating care for patients across care settings. The model allows providers to move more rapidly from a shared savings payment model to a population-based payment model on a track related to, but separate from, the MSSP.
"Summary." U.S. Bureau of Labor Statistics. U.S. Bureau of Labor Statistics, n.d. Web. 20 May 2014.
"Summary." U.S. Bureau of Labor Statistics. U.S. Bureau of Labor Statistics, n.d. Web. 30 Apr. 2014.
"Summary." U.S. Bureau of Labor Statistics. U.S. Bureau of Labor Statistics, n.d. Web. 19 Mar. 2014.
We no longer had to wait for a doctor to come our house or have family member care for us, we now had hospitals to go when we were ill, we had doctors with degrees and nurses to attend to our needs but how would we pay for such things? In the 1930’s there was a great rise in healthcare costs. At this time most all doctors were paid by a “fee-for-service” program. New insurance plans like Blue Cross and Blue Shield of America offered members to pay for the costs of being hospitalized and for the treatment the physician had given to them. The AHA decided to take a role in group hospitalization plans and during the World War II a new medical plan was started by a man named Henry J Kaiser, he offered his employees’ a pre-paid medical insurance plan. This is what paved the road to what know how as a Healthcare Maintenance Organization or an HMO.
United States Department of Labor (2004) Occupational Safety & Health Administration. In Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers. Retrieved from http://www.osha.gov/Publications/OSHA3148/osha3148.html
(8) U.S. Dept. of Labor, Family and Medical Leave Act – Wage and Hour Division (WHD) (http://www.dol.gov/whd/fmla/), 2013, Website
UNITED STATES DEPARTMENT OF LABOR. (n.d.). U.S. Department of Labor. Retrieved February 5, 2014, from http://www.dol.gov
“Summary” Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2012-13 Edition, Actuaries, 5 Apr. 2012. Web. 15 Nov. 2013.Handbook, 2012-13 Edition, Actuaries, 5 Apr. 2012. Web. 15 Nov. 2013.