FAP1 FAP TASK 1 Federal Government Payer Program PDF

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Federal Government Payer Program Stacey Pierce Student ID – Spie151 Healthcare Ecosystems – C799 Western Governors University Course Instructor – Penny Harris

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A1. Medicare impacts certification within today’s healthcare ecosystem because it requires a certification for providers in each state. The Centers for Medicare and Medicaid Services (CMS) oversees certification for numerous continuing care providers (including nursing homes, hospitals, home health agencies, hospices, end-stage renal disease facilities, and other facilities serving Medicare and Medicaid beneficiaries). CMS also makes this information accessible to beneficiaries, providers and suppliers, researchers, and state surveyors. Government and non-government organizations use certification to diligently research programs, facilities, and individuals to ensure they are meeting standards. Medicare certification information is easily viewable via the web. Data.medicare.gov is an excellent tool within our Healthcare Ecosystem since it enables the consumer to compare, study, and download data on multiple providers. Overall, certification is needed in our Healthcare Ecosystem today. Holding a certification, though, also means they are adhering to CMS guidelines to maintain it. “CMS develops Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs. These health and safety standards are the foundation for improving quality and protecting the health and safety of beneficiaries.” (Centers for Medicare & Medicaid Services, n.d.-a). Therefore, certification ensures the provider will comply, and compliance is everything in today's world. Americans do not want to give their services to an agency or facility that does not hold a certification. This level of achievement is a gold sticker in our Healthcare Ecosystem. The public wish to have all the information possible on their potential hospital stay, assisted living, home health agency, or doctor's office. Therefore, Medicare certification impacts the Healthcare Ecosystem because it gives consumers peace of mind, is a safeguard, and ultimately provides trust for the community.

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A2a. Medicare affects clinical quality reporting because participating in the Medicare/Medicaid programs requires the provider to submit eCQMs. Electronic clinical quality measures (eCOMs) use the data from EHR or a health information technology system to measure health care quality. The reporting assists with tracking and measuring the quality of healthcare services that eligible hospitals, eligible professionals (EPs), and critical access hospitals (CAHs) provide. Quality of care for efficient, patient-centered, effective, safe, equitable, and timely care is essential in today's healthcare ecosystem. Additionally, clinical quality reporting is a measurement for payment. For Physicians, the Merit-based Incentive Payment System (MIPS), implemented in January 2017, is a clinical quality reporting system based on the clinicians' physical data. The data is broken down into four different areas (Quality, Promoting Interoperability (formerly Advancing Care Information), Improvement Activities, and Cost). The MIPS goal is to tie payments to drive cost-efficient care, increase healthcare information usage, improve in care processes/health outcomes, and ultimately reduce the cost of care. Hospitals use a different program; the Hospital Value-Based Purchasing (VBP) Program is a CMS initiative that will reward acute-care hospitals with incentive payments for the quality care they provided to Medicare beneficiaries. Hospitals now are not solely paid on the number of services offered. Under the Hospital VBP Program, Medicare generates incentive payments to hospitals. The incentives are based on how well they perform on each measure compared to other hospitals' performance/how much they improve their performance during a baseline period. Therefore, Medicare has a significant influence on clinical quality reporting in today's healthcare ecosystem. Without clinical quality reporting, there would be no metrics/measures for care, and physicians/hospitals would not be reimbursed correctly or at all. In summary, clinical quality

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reporting is necessary for our healthcare ecosystem to show that the agency is operating within CMS guidelines. A2b. Medicare affects reimbursement for healthcare services because reimbursement under Medicare refers to the payments that hospitals and physicians receive in return for services provided to Medicare beneficiaries. Reimbursement rates for services are set solely by Medicare. “A Prospective Payment System (PPS) is a method of reimbursement in which Medicare payment is made based on a pre-determined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service (for example, diagnosis-related groups for inpatient hospital services). CMS uses separate PPSs for reimbursement to acute inpatient hospitals, home health agencies, hospice, hospital outpatient, inpatient psychiatric facilities, inpatient rehabilitation facilities, long-term care hospitals, and skilled nursing facilities.” (Centers for Medicare & Medicaid Services, n.d.-b). Therefore, different providers will receive various payments because of the type of service. Medicare affects reimbursement for physicians and hospitals in a separate metric. Hospitals contract with Medicare to furnish acute inpatient hospital care and agree to accept pre-determined IPPS (Acute Care Hospital Inpatient Prospective Payment System) rates as payment in full. Specifically, 90 days of care (per episode of illness) with an additional 60-day lifetime reserve is what the inpatient hospital benefit will cover. Medicare will pay acute care hospitals an IPPS payment on a per inpatient case or per inpatient discharge basis. The claim for the inpatient stay is required to include all outpatient diagnostic services and admission-related outpatient non-diagnostic services in the admitting hospital. On the other hand, as directed by CMS, physicians use the Resource-Based Relative Value Scale (RBRVS) as a payment system. The RBRVS is based on the principle that payments for physician services should vary with the resource costs for

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providing those services. The intention is to improve and stabilize the payment system while providing physicians an avenue to improve it. In this system, payment measures generate by the specific resource costs needed to provide them; each service is divided into three components (practice expense, physician work, and professional liability insurance). Payments are then calculated by multiplying the combined costs of a service, then multiplying a conversion factor (amount determined by CMS) and adjusting for geographical differences. Therefore, IPPS & RBRVS are significant factors of reimbursement for Medicare, both for physicians and hospitals, to drive our healthcare ecosystem. Multiple factors weigh in on payment for services. Overall, Medicare affects reimbursement in our healthcare ecosystem today; whether it is a hospital or a doctor's office, the statements above show each relies on reimbursement uniquely. A2c. Medicare influences patient access to care. Medicare is available for those aged 65 or older, the young with disabilities, and those with End-Stage Renal Disease. Medicare has two parts, Part A (Hospital Insurance) and Part B (Medicare Insurance). Other factors that influence access to care include being a citizen of the United States or being a legal resident for at least five years. While most people do not have to pay a premium for Part A, everyone must pay for Part B if they want it. This monthly premium gets deducted from Social Security, Railroad Retirement, or Civil Service Retirement check. If payments do not come from the programs mentioned, Medicare sends a bill for the Part B premium every three months. Having this plan available is a significant advantage for access to care within the healthcare ecosystem today. Although there have been some changes, such as implementing the Affordable Care Act (ACA) in 2010, there was no evidence that supported a decline in access to care. Consumers and providers opt-in to this payor source, allowing more patient access to care. Medicare also relies heavily on clinical quality reporting; patients have ample access to resources on comparing

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providers. Medicare continues to stay up to date with community needs. Specifically, Telehealth became more available to Medicare beneficiaries during COVID-19. Telehealth had a significant impact on patient access to care, especially the elderly, to re-fill a prescription or manage a chronic condition was just a phone call away. Patient access to care is an example of the quality of care since, without access, there would not be quality. Medicare places ample information regarding their different options straight onto their website (https://www.medicare.gov/). With most major hospitals and doctors’ offices familiar with Medicare, this paves the way to providing patients with access to care. B. A specific role within Health Information Management that supports the Medicare payer program is a Clinical Informatics Specialist. Working in this role, we support the Medicare payor every day by completing an overview of clinical documentation, verifying licensure, accreditation, and providers' certification to ensure accuracy for billing Medicare. Being embedded in both analyzing clinical documentation and fixing potential billing issues involved with the Medicare payor is a vital portion of HIM and in the duties of a Clinical Informatics Specialist. Acquiring, analyzing, and protecting digital and traditional medical information is essential to providing quality patient care and adhering to the goals of the Medicare Payor. It would be best to think of all the pieces that it takes to support the goals of Medicare with this role. When a referral begins, the physician's credentials are verified and PECOS enrollment (Provider, Enrollment, Chain, and Ownership System. Physicians who care for Medicare patients should enroll in PECOS to ensure their patients can receive the care and supplies they need). Once the physician is verified, then within this role, we are checking Medicare as the payor. These steps all support the goals of Medicare as the payor source because it is standard for quality of care. Once the clinical staff completes their charting, we need to ensure that coding is

Federal Government Payer Program appropriate for Medicare, and the documentation supports the diagnosis. Last, maintaining the medical record and ensuring compliance helps support the goals for Medicare within this HIM role.

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Centers for Medicare & Medicaid Services (n.d.-a). Conditions for Coverage (CfCs) & Conditions of Participation (CoPs). Retrieved from https://www.cms.gov/Regulations-andGuidance/Legislation/CFCsAndCoPs Centers for Medicare & Medicaid Services (n.d.-b). Prospective Payment Systems - General Information. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/ProspMedicareFeeSvcPmtGen#:~:text=A%20Prospective%20Payment %20System%20(PPS,groups%20for%20inpatient%20hospital%20services)....