Explain Medicare payment systems, coding, pricing and billing and their impact on financial performance and decision making.
Type: Individual Project – Unit 5
Obejectives:
-Explain Medicare payment systems, coding, pricing and billing and their impact on financial performance and decision making.
-Assess financial data sources and make recommendations for data reporting in support of decision making.
Research Paper
Search course materials, including your text and the Internet, to find a spreadsheet program that will assist you in completing this assignment. The spreadsheet and calculations are to be attached at the end of the paper as an appendix after the Reference page.
Case Study: You are assessing the payer–patient mix for a health care organization. Currently, your payer mix is 40% Medicare, 10% Medicaid, 25% traditional indemnity insurance, 20% managed care, and 5% self-pay patients. Complete the following:
• Using the most common office visit, CPT code 99214, determine the reimbursement from the Centers for Medicare and Medicaid Services (online fee schedule available for Medicare).
• Using the same CPT code, 99214, determine the reimbursement for Medicaid (fee schedules should be available from the individual state).
• Using the same CPT code, 99214, create at least 3 other traditional indemnity insurance reimbursements. If possible, use the actual reimbursement from the insurance carrier. It may be possible to obtain actual reimbursement information from your personal insurance carrier. If the information is not available, assume reimbursement by traditional indemnity insurance is usually 200% reimbursed more than Medicare and Medicaid, and managed care is usually 133% more than Medicare and Medicaid.
• Compose an accounts receivable benchmark from this information showing columns for current, 30–60, 61–90, 90–120, and greater than 120 days.
• Assess the information for areas of improved reimbursement of at least 20% or more.
• Evaluate the options available to change the payer–patient mix with consideration of related legal and ethical issues.
• Propose a best strategy with justification and rationale based on effective decision-making tenets.
The body of the resultant paper should be 10–12 pages. Spreadsheets demonstrating the accounts receivable analysis will be attached as appendices, and there will be at least 7 relevant peer-reviewed academic or professional references published within the past 5 years. Also attach appropriate fee schedules.
Grading Criteria Percentage
Deliverable requirements addressed; understanding of material and writer’s message and intent are clear 35%
Scholarly research which supports writer’s position properly acknowledged and cited direct quotations may not exceed 10% of the word count of the body of the assignment deliverable (excluded title page, abstract or table of contents if used, tables, exhibits, appendices, and reference page(s). Inclusion of plagiarized content will not be tolerated and may result in adverse academic consequences. 20%
Critical thinking: position is well justified; logical flow; examples 20%
Structure: includes introduction and conclusion; proper paragraph format and reads as a polished, academic paper or professional presentation, as appropriate for the required assignment deliverable 10%
Mechanical – no spelling, grammatical or punctuation errors 10%
APA – deliverable is cited properly according to the APA Publication Manual (6th Ed.) 5%
Additional Information:
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e-book chapter
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TEACHER NOTES
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You are assessing the payer–patient mix for a health care organization. Currently, your payer mix is 40% Medicare, 10% Medicaid, 25% traditional indemnity insurance, 20% managed care, and 5% self-pay patients. Complete the following:
• • Using the most common office visit, CPT code 99214, determine the reimbursement from the Centers for Medicare and Medicaid Services (online fee schedule available for Medicare).
• • Using the same CPT code, 99214, determine the reimbursement for Medicaid (fee schedules should be available from the individual state).
• • Using the same CPT code, 99214, create at least 3 other traditional indemnity insurance reimbursements. If possible, use the actual reimbursement from the insurance carrier. It may be possible to obtain actual reimbursement information from your personal insurance carrier. If the information is not available, assume reimbursement by traditional indemnity insurance is usually 200% reimbursed more than Medicare and Medicaid, and managed care is usually 133% more than Medicare and Medicaid.
• • Compose an accounts receivable benchmark from this information showing columns for current, 30–60, 61–90, 90–120, and greater than 120 days.
• • Assess the information for areas of improved reimbursement of at least 20% or more.
• • Evaluate the options available to change the payer–patient mix with consideration of related legal and ethical issues.
• • Propose a best strategy with justification and rationale based on effective decision-making tenets.
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