Reimbursement Methodologies

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Tawana Knox-Bowers
7708 Verona Dr.
Fort Wayne, Indiana 46816
Student Number: 20705965
Examination Number: 409761

1. You’re the new director of a hospital health information management department. The chief financial officer has haired you for your expertise in health care reimbursement and needs to know how your department can help with reimbursement. List the most important functions of health information management.

There are several different things the health information manager can do to help with reimbursement. Ensuring that the proper codes have been assigned and that there is adequate documentation. The health information management department staff may also analyze case mix, manage on going reimbursement and quality issues, ensure that health record documentation supports services billed, assign diagnostic and procedural codes according to patient record documentation, apply coding guidelines and edits when assigning codes or auditing for coding quality and accuracy. This department may also assist in appealing insurance claims denials. 2. Describe the importance of Blue Cross and Blue shield plans in the evolution of health care coverage.

Blue Cross and Blue Shield were the first prepaid health plans in the United States. Blue Cross/Blue Shield include a full range of health care services that cover 28.6 percent of the U>S. population. Blue Cross/Blue Shield Federal Employee Program (FEP) is the largest privately underwritten health insurance contract in the world. The FEP offers 2 plans, the PPO and the POS. The Blue Cross plan has been evolving since 1929 and the Blue Shield since 1939. 3. Explain why the lack of universal health care coverage can raise health care costs.

Many studies have show that people without health insurance do not get the health care they need. The sicker they become, the more tests, surgeries, and other health care services they need. This scenario increases costs to the health care industry. If public health is improved, then the population becomes healthier and health care costs should decrease. A good initiative to move toward a healthy population is the Healthy People 2010 program. 1. You work in the hospital’s health information management department. Part of your job is to assist the medical residents with completing records documentation. One of the residents complains that he doesn’t understand why insurance companies need so much documentation and the reimbursement system is so complex. How do you respond.

In order to serve the patient and help to provide quality care, it is important to have a complete and accurate medical record. Keeping records complete and accurate will help in figuring out reimbursement costs and discovering what costs are covered. It is also very important to keep track of all services and supplies so that the hospital can be reimbursed. 2. Mary was receiving Medicaid in Texas. When she moves to California, can Mary assume that she’ll receive the same coverage there?

Medicaid policies on eligibility services and payments are complex and very considerably from state to state. Thus, Mary may not be eligible in California even though she was in Texas. 3. Compare point-of-service (POS) plans with health maintenance organization(HMO) plans.

In an HMO plan, the insured must choose a primary care physician and then must obtain a referral to seek care from a specialty physician. In a POS plan the insured chooses a primary care physician but still has the option of receiving care from other physicians without the need for a referral. POS combines the features with thos of the PPO. 4. You’re an inpatient coder in a hospital. You’ve just coded a Medicare Part A record with a diagnosis-related group (DRG) reimbursement of $12,000. You notice in the hospital’s computer billing system that the patient’s charges are $19,500. That’s $7,500 more than the hospital will be reimbursed. How does the...
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