Payers associated with reimbursement of health services include government and other commercial payers. The payers make sure that inpatient, outpatient, and non-patient services are efficiently processed in accordance with state laws and regulations. The largest payers of healthcare services are Medicaid and Medicare. Medicare has various plans offering different coverage. The plans in Medicare are plans A, B, C, and D. Plan A is based on employment while Plan B is based on insurance covers for medical services administered to patients. Medicare plan C covers Provider Sponsored Organizations (PSOs). The Medicare Plan D insurance covers access to medical prescriptions at a lower cost.
Reimbursement of insurance in healthcare
Other forms of government reimbursement insurance in healthcare include TRICARE and CHAMPVA which cover medical services for the military service members and their families. TRICARE provides many options where TRICARE Prime covers comprehensive health services such as emergency, preventative care, inpatient, and outpatient services. TRICARE standard is another option that offers fee-for-service plans to non-active members in the U.S, but they must be registered in DEERS. The last option is TRICARE for life that provides secondary coverage to members of Medicare plan A and B. the coverage is available worldwide making TRICARE a medical payer.
Worker’s compensation may also be used to help employees cover their medical expenses that are workplace-based. State Children’s Health Insurance Program (CHIP) is another form of insurance cover for children of low income who do not qualify for Medicare. To qualify for this program, the children must fall below 200 percent of the federal poverty level. Programs for all-inclusive Care for the Elderly (PACE) helps in providing care to the elderly.
Health Insurance Portability and Accountability Act ( HIPAA)
A supplier of health care services is a physician or entity that furnishes health services under Medicare. Suppliers must meet the guidelines of the Medicare Integrity Program. Suppliers who meet the guidelines must enroll and bill Medicare as a result. The supplier must present a claim to the third party organization for payment of the services provided. In completing the claim all the information to the patient must be filled. Two types of claims; institutional and professional are used. CMS 1500 and CMS 1450 are used. CMS 1500form represents physician and outpatient medical services. CMS 1450, on the other hand, submits charges using the Health Insurance Portability and Accountability Act (HIPAA).
Ethics in Health Care
Ethics are very important to any profession. In payers and suppliers of medical services, ethics should be followed since many healthcare organizations operate by ethical values that determine the success of the organizations. Health care organizations operate in an industry that requires high morals and ethical standards to provide the best healthcare services to the patients. The payers and suppliers in healthcare must adhere to state and federal laws and regulations relating to the submission of claim forms. The claims must, therefore, be accurately filled since the failure to do so may result in suing of the supplier organization.
Consumers want affordable and reliable medical services. The big challenge in health care is cost containment since the cost should not affect the delivery of health services. Insurance companies should also uphold ethics in their profession. They should understand that without the consumers they would not understand. They should, therefore, charge reasonable premiums.
The application of ethics in the medical profession is very important in ensuring the delivery of quality patient care that is affordable and cost-effective. The payers and suppliers of health care services should not be too restrictive as that leaves the patient at a disadvantage. Patients should be given options of how the services are provided so that they can choose and feel in control of their lives.
Assessing the impact of regulations on reimbursement.
HIPAA provides that it is mandatory for healthcare organizations to follow the regulations because, without them, the payers will not reimburse for the services. A health care organization may be fined or closed for not following the regulations. According to Homework Help, Billing and coding are a very complex issue that should be updated continuously. Challenges occur to the reimbursement of health services as a result of mistakes that might be done. One of the challenges is incorrect documentation which may lead to delays in payment or inappropriate payment to an organization. Medicare fraud is abuse that would expose the providers of health services to civil liability. Fraud prevention systems in healthcare should be implemented to improve health care costs. For instance, the government recovered more than 4 billion dollars from people committing fraud. Another tool that could assist in following the regulations is the Federal Register which is updated annually.