Medicaid Fee Schedule: Case Study

Quality physician documentation is not only essential to providing superior clinical communication, but also allows for the delivery of useful data that “supports quality metrics, acuity of care, billing, and accurate representation of medical conditions” (Rosenbaum et al., 2014). The Centers for Medicare and Medicaid Services (CMS) uses a system to classify Medicare patient’s hospital stays into various groups in order to facilitate payment of services called Medicare Severity-Diagnosis Related Group (MS-DRG). Some payers also use all patient refined (APR)-DRG reimbursement systems. MS-DRG groups are outlined by a specific collection of patient characteristics which include areas specific to the “principle diagnosis, specific secondary diagnoses,

On this date worker received a call from Ms. Kimbrell, Medicaid Caseworker. Ms. Kimbrell stated Mr. Duncan's nephew who is living at the residence in Curry would need to fill out a Statement from Dependent Relative/Community Spouse form. Because he is living in a home, Mr. Duncan is part owner. She also stated Mr. Duncan would be denied institutional Medicaid because he was not transferred to a long-term facility. However, he could receive hospital Medicaid because he was in the hospital longer than 30 days. The transfer penalty does not apply to hospital Medicaid but if Mr. Duncan ever applies for institutional Medicaid, they would need the person who purchased the home from Mr. Duncan to provide something showing the amount of money he spent

Medicaid will paid for the remaining balance that the primary insurance don't cover if that balance is part of the charge fee. Usually patient paid at front for they copay if they want to paid us and we go to submit the claim to the patient 2ndry insurance with copy of the primary payment EOB and Medicaid will paid us the rest of the balance of the patient charge fee visit without passing over the Medicaid encounter rate fee. Sometimes Medicaid paid in full and we have to refund to the patient the copayment that the patient paid from the primary payer but this is hard to know because is depending of the patient coverage with the primary insurance.

In the healthcare environment, the challenges that providers face are revenue shortfalls due to insufficient payments from the reduction of Medicare reimbursement rates (Shi and Singh, 2015. p238). Payers that have employment-based insurance are charged extra to cover the remaining balance. This process is called cost shifting. In some healthcare systems, the relationship between reimbursement reduction and cost shifting is correlated in an inversely proportional trend. As the decrease in reimbursement from public insurance such as Medicare and Medicaid, the method of cost shifting would increase.

When this provider bill with rev codes, they are receiving a payment but then they bill out-patient services they’re receiving a denial G18. Do you know how this provider is set-up to bill?

The A single-payer national health program (NHP) has similarity to the Affordable Healthcare Act. However, it better because is addresses some of the issues that were left out of the ACA. Like, free choice of providers and the preservation of doctor–patient relationships are threatened by our current system (Gaffney, Woolhandler, Angell, & Himmeslstein, 2016). With each enrollment cycle, patients seeking affordable premiums or changing jobs must often switch insurers and risk breaking existing relationships with providers.

I just want to share this information with you. When the F.A department complete the patient sliding fee scale documentation the patient needs to sign the contract where show on the form what type of scale the patient qualify and how much will be their copayment according to their scale levels. For example: The patient with the account 13010460 the scale level is scale F and was circle to the patient that he is responsible for the copayment of $80 dollars and for Dental $100 and for the rest of the charge fee amount .The patient was agree and sign the document. Please review the attach document. PMG can use that information to remid the patients that they was agree with the scale when the F.A department complete the process with

Medicaid Administrative Costs - It is possible to obtain reimbursement for administrative activities directly related to Medicaid for either obtaining Medicaid coverage or assisting beneficiaries in obtaining care. To begin the process, there will need to be a discussion with the state Medicaid office and completion of several pieces of documentation before billing for costs can occur. It will require a written plan and documentation of time spent on the administrative activities. The two specific types of reimbursement are Medicaid Administrative Claiming (MAC) and Targeted Case Management (TCM).

Following the death of a Medicaid recipient, the program not only can but must attempt to recover costs from the estate of the deceased. Medicaid's official site says:

The Affordable Care Act (ACA) has been the biggest milestone to date in American health care policy (Saldin, 2011). There is nothing more complex or controversial in recent history than the passing of the ACA in 2010 (Davidson, 2016). The United States Supreme Court ratified the constitutionality of the Patient Protection and Affordable Care Act on June 28, 2012. With this, there were certainly challenges facing the full implementation of the provisions of this act by 2014.

With the implementation of the ACA, many states have expanded their Medicaid programs to include a larger population of low income individuals and families that were not able to obtain health insurance prior to the law. Some of the issues that state legislators struggle with are the overall cost of providing services for the additional recipients, staying within budget, determining an adequate approach of offering quality care, and providing adequate coverage for each recipient. Even though the cost of Medicaid expansion within each state has increased the budget for the program, new appraisals has shown that Medicaid programs spend less per enrollee than commercial health insurance and much of the increase in Medicaid expenses originate from the increase in enrollment in the programs (Coughlin, Long, Clemens-Cope, & Resnick, 2013).

People don’t like being sick, however, some Missourians forego preventive care, required doctor visits and beneficial medicines because they cannot afford them. They may be working in part time jobs, seasonal jobs or other unskilled labor jobs and lack affordable health insurance. They are the poor people below the 138% federal poverty level (FDP). According to Chris Kelly, a former Representative of the Missouri House for district 24, the West Plains hospital Ozark Medical Center’s (OMC) service area includes more than 9,000 uninsured adults (p1). So, what do you do when you are poor and sick and can’t afford a doctor’s visit? You go to the emergency room of a local hospital and the hospital absorbs that

Providing grants to health care facilities with Medicaid patients will enable these sites to conform with the goal. So your proposed idea of providing grants to small offices and rural hospitals needs to be considered. My cousin (he is a vascular doctor) opened an office in Florida and had to close it because payment issues with patients receiving Medicaid. As you can tell, Medicaid has limited budget therefore will affect those receiving Medicaid benefits.

Affordable care act is a law that was passed in March of 2010 to help decrease health care cost and make it more affordable for all Americans. The affordable care act is set to decrease the number of uninsured Americans, qualify more for Medicare and Medicaid, increase the quality of care, promote prevention, extending funding for the children, and help with funding in the communities. The goal for affordable care act is to have everyone insured, no matter what income class you are in. The affordable care act is there to insure everyone so that prevention will increase. It will increase by being able to get check ups and children being able to receive vaccination. If you are not able to qualify for Medicare or Medicaid there

Medicaid initially established that each state is responsible for designing their medical costs to pay medical care for the poor. Also, Medicaid created as a voluntary program for each state; they have to have the choice to participate. For one thing, because of the rising costs of healthcare, it has been difficult to bring Medicaid recipients into the “mainstream” of United States (U.S.) medical care. Donald R. Barr notes, “between 1975 and 1989, the cost of the Medicaid program increased by an average of 11.9 percent per year before adjusting for inflation” (172). The rising costs of healthcare are necessary for each state to determine if it is beneficial for them to participate in the Medicaid program. As the government level of payment is determined by each state economic condition. For instance, a state with lower per capita income will receive more government funding. A state with higher per capita income receives less reimbursement for program costs. Therefore, on December 31, 2010, many states continued to experience budget cuts. As a result on August 2010, Congress increased reimbursement rates through June 2011.