Federal government payer program

Disclaimer: All notes and tips for this task pertain to the use of Medicare. The assignment allows for a review of other federal government payer programs. 

Heres an abbreviated set of notes for Task 1 that might help you focus if you are using Medicare as your Federal Government Payer as you cover both physicians and hospitals throughout the paper.

Each writing prompt below aligns with the rubric for the task.

A. Impact on Standards

Analyze one federal government payer program for healthcare services (i.e., Medicare, Federal Employees Health Benefits Program, Indian Health Service, or TRICARE) making an impact on todays healthcare ecosystem by doing the following:

The Centers for Medicare and Medicaid – https://www.cms.gov/

Writing Prompt 1: Impact on Standards

A1. Explain how your chosen federal government payer program impacts licensure, certification, or accreditation standards.

Tip: Choose 1 of the 3 but be sure to cover both physicians and hospitals and show the impact on the physician and hospitals reimbursements if they do not become a participant. 

Textbook Resources: Chapter 1: HIM text: https://wgu.vitalsource.com/#/books/9781584267577/cfi/6/26!/4/2/2/2@0:0

1. Licensure Both physicians and hospitals must be licensed by the state where they practice.

2. Certification Medicare will certify physicians and hospitals for the scope of medicine they are allowed to practice and file claims for.

If the hospital chooses not to go through the expensive and time-consuming accreditation process with an organization such as Joint Commission or DNV Healthcare, they are still allowed to participate with Medicare.  

For physicians, you will need to review the Physician Enrollment Contract – https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/Enroll-as-an-Institutional-Provider

Physician Enrollment forms: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855i.pdf beginning on page 5.

For hospitals, you will need to review the Conditions of Participation for Hospitals 

https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/Downloads/CMS-3244-F.pdf

CoP Hospital Enrollment through PECOS: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/Enroll-as-an-Institutional-Provider

3. Accreditation Hospitals may be voluntarily accredited by a national accrediting organization like Joint Commission (JC) or DNV Healthcare in order to waive the large number of standards necessary to participate with Medicare. Physicians can never be accredited since JC and the DNV only accredit hospitals and facilities, not the providers themselves. Accreditation by an Accrediting Organization (AO) is voluntary and is not required for Medicare certification or participation in the Medicare Program. A providers or suppliers ability to bill Medicare for covered services is not impacted if it chooses to discontinue accreditation from a CMS-approved AO or change AOs.

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Accreditation-of-Medicare-Certified-Providers-and-Suppliers#:~:text=Accreditation%20by%20an%20AO%20is%20voluntary%20and%20is,accreditation%20from%20a%20CMS-approved%20AO%20or%20change%20AOs.

Discuss the Impact on Reimbursement for Hospitals and Physicians from Medicare and/or the Patient Only

Participating, Non-Participating, and Opt-Out Providers https://www.medicare.gov/your-medicare-costs/part-a-costs/lower-costs-with-assignment 

Participating providers agree to accept assignments on all claims submitted for Medicare patients. 80% from Medicare and 20% from the patient, and to hold patients responsible only for amounts up the 20% coinsurance plus any unmet deductibles. Non-participating providers accept Medicare but do not agree to take an assignment in all cases (they may on a case-by-case basis). This means that while non-participating providers have signed up to accept Medicare insurance, they do not accept Medicares approved amount for health care services as full payment, and may charge patients more for services, typically from a fee schedule. Opt-out providers do not accept Medicare at all and have signed an agreement to be excluded from the Medicare program. Patients are responsible for directly paying the opt-out providers based on their contract for services.

Writing Prompt 2: Clinical Quality Reporting Systems

A.2a. Explain how your chosen federal government payer program influences each of the following:

a. Clinical Quality Reporting Systems 

Tip: Focus only on the reporting systems not the quality measures since they are generated by clinical personnel not HIM staff. Show the impact on the physician and hospitals reimbursements if they do not use the required reporting systems.

Merit-based Purchasing Systems for physicians (MIPS) AND

Value-based Purchasing Systems for hospitals (VBPS)

Here are the links to help with this only IF you are using Medicare as your Federal Government Payer if you are using one of the others, you will need to look on the Managed Care Contract to find the specific name of the quality reporting system:

Quality Reporting System for outpatients under Medicare

Merit-based Incentive Purchasing Systems for physicians (MIPS) – https://qpp.cms.gov/mips/overview

https://www.practicefusion.com/quality-payment-program/what-is-mips/

Value-based Purchasing Systems for hospitals (VBPS) https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Hospital-Value-Based-Purchasing-

Writing Prompt 3: Reimbursement for Healthcare Services

A.2b. Explain how your chosen federal government payer program influences each of the following:

b. Reimbursement for Healthcare Services

Textbook Resources: Chapter 7: HIM text: https://wgu.vitalsource.com/#/books/9781584267577/cfi/6/40!/4/2/2/2@0:0

Medicare Part A for hospitals with Inpatient Prospective Payment Systems (IPPS) formula

Medicare Part B for physicians with Resource-Based Relative Value Scale (RBRVS) formula

Tip: Five questions to answer generally for each. These questions are not to be interpreted literally, instead collect the responses for each and use the response to complete the discussion.

What is the claim filing process?

How is the assignment received and accepted for the reimbursements?

Is there an allowable fee schedule?

Is there a contractual write-off?

Can the patient or patients 2nd insurance be balance-billed for the contractual write-off amount?

Also, Show the impact on the physician and hospitals reimbursements if they do not become a participant.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/HospitalOutpaysysfctsht.pdf

https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched

Writing Prompt 4: Patient Access to Care

A.2c. Explain how your chosen federal government payer program influences each of the following:

c. Patient Access to Care 

Tip: Be sure to discuss how Medicare directly impacts the patients access to care. You may choose to discuss examples that Medicare influences to increase access or examples that Medicare influences to hinder access such as the impact of physicians opting out or the shortage of PCP. Either option you choose, be sure that the discussion highlights how patient access to care is influenced.

Shortage of PCPs coming out of U.S. Medical Schools-Article attached

Physicians Opting Out of Medicare-Article attached

https://www.medicareinteractive.org/get-answers/medicare-covered-services/outpatient-provider-services/participating-non-participating-and-opt-out-providers

Telehealth & Related Services/Other ways Medicare is helping: https://www.medicare.gov/medicare-coronavirus

Writing Prompt 5: HIM Role

B. Evaluate how health information management plays a part in your chosen federal government payer program by discussing a specific professional role within the HIM profession and how the role supports the goals of the chosen federal government payer program.

Tip: Role of Health Information Management Professional

Name specific HIM role

Show the effect Medicare regulations has on that specific role

https://my.ahima.org/careermap/index.html

C. Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.

Tip: For additional support with APA please refer to the attached documents.

If you use a source to gather the information that you use in paraphrased sentences and paragraphs then you must have an in-text citation inside your work at the end of the last paragraph of such paraphrasing.

If you directly quote a sentence or two (and no more than that per paper), immediately after the closing quotation marks, you must have an in-text citation inside your work.

Task 1 is now complete! If you would like for me to review your completed work before submission, you may email it to me and if you have any questions please feel free to reach out to me at any time by email, or schedule an appointment.