Please prepare a half page response for each part:
Part 1,
The mere fact the Medicare billing guidelines have over three hundred pages, it is indication of the complexity of the process overall. After reviewing the guidelines and the level of detail to which they have actually been written, I am of the opinion they do not serve a good purpose.
Paper instructions:
Please prepare a half page response for each part:
Part 1,
The mere fact the Medicare billing guidelines have
over three hundred pages, it is indication of the
complexity of the process overall. After reviewing the
guidelines and the level of detail to which they have
actually been written, I am of the opinion they do not
serve a good purpose. While it is understood there
needs to be guidelines that will regulate reimbursement
rates based on services delivered and their geographic
areas, the paper billing process is complex,
cumbersome and gives opportunity to the fraudulent
activity that has been seen for many years.
A review of the claims processed by Medicare from
2001 to 2010 yield the following key findings: 1)
healthcare professionals have steadily billed Medicare
higher rates resulting in $11 billion dollars of inflated
charges, 2) up-coding or charging for more complex
services than those delivered, 3) much of the increase
of higher billing practices seems to happen in hospital
emergency rooms, and 4) an increase in the abuse of
billing for costly services seems to be on the rise due to
lax oversight and the transitioning to electronic records
which can actually contribute to the billing abuse
(Schulte and Donald, 2012). With the reimbursement
rates from Medicare for physician services not keeping
pace with the rising costs of inflation which physician
offices are faced with, it has left them no alternative but
to find creative ways to make ends meet. While CMS
feels most physicians and hospitals are honest in their
billing practices, it has left room for the occasional
overbilling which is costing taxpayers millions of dollars
on a yearly basis. It is understandable that costs for
medical services will vary based on geographic area,
however in order for the system to work it is also
necessary for the system to take into account the
economic factors, such as inflation that impact the
healthcare providers when establishing the
reimbursement rates.
Part 2
I do not believe Medicare billing guidelines are
served well. Medicare is the federal health insurance
program for the elderly and disabled. There are two
major Medicare programs-Part A and Part B. Part A
covers some areas such as hospitalization, hospice,
skilled nursing facilities, and some home health services.
Part B covers some areas such as physician services,
outpatient hospital services, laboratory charges,
medical equipment, and other home health services.
The federal government spent a lot on Medicare
services in the past years. According to the data from
Social Security Administration, the budget on Medicare
services increased from $57.9 billion to $271 billion in
2003 (Levinson, 2013). In order to reduce costs and
prevent fraud, the government created a complex
regulatory structure for Medicare billing and
reimbursement. The Medicare billing guidelines are
complex and vague in some areas, such as elective
surgeries, initial services, and collaboration. In terms of
initial services, the advanced practice registered nurse
(APRN) may or may not be able to charge
independently for a patient with a chronic medical
condition but a new complaint, say a diabetic patient
who now has difficulty breathing, depending on
whether “initial service” reflects the initial visit for
diabetes management or the initial visit for the new
complaint of dyspnea. The governments should clarify
the standard for initial service.
Medicare Part A provides inpatient hospital
insurance benefits and coverage of extended care
services for beneficiaries after they are discharged from
hospitals. Medicare requires that certain elective
surgeries be performed in an inpatient hospital setting.
According to research by Dainel Levinson, in the
calendar years 2009 and 2010, Medicare made Part A
prospective payments to hospitals of $597 million for
inpatient claims that involved a canceled elective
surgery. Almost $55 million involved short-stay (2 days
or fewer) claims (Levinson, 2013). When an inpatient
hospital admission is based on the expectation that a
patient will have elective surgery but that surgery does
not occur, that cancellation would generally make the
admission not reasonable and necessary. The
government should revise the admission policy for
elective surgeries to reduce claims for patients who did
not have surgery in a hospital.
