Explaining Medicare payment systems, coding, pricing and billing and their impact on financial performance and decision making


Description

Assess financial data sources and make recommendations for data reporting in support of decision making.

Explain Medicare payment systems, coding, pricing and billing and their impact on financial performance and decision making.

Search course materials, including your text and the Internet, to find a spreadsheet program that will assist you in completing this assignment. The spreadsheet and calculations are to be attached at the end of the paper as an appendix after the Reference page.

Case Study: You are assessing the payer–patient mix for a health care organization. Currently, your payer mix is 40% Medicare, 10% Medicaid, 25% traditional indemnity insurance, 20% managed care, and 5% self-pay patients. Complete the following:

Using the most common office visit, CPT code 99214, determine the reimbursement from the Centers for Medicare and Medicaid Services (online fee schedule available for Medicare).
Using the same CPT code, 99214, determine the reimbursement for Medicaid (fee schedules should be available from the individual state).
Using the same CPT code, 99214, create at least 3 other traditional indemnity insurance reimbursements. If possible, use the actual reimbursement from the insurance carrier. It may be possible to obtain actual reimbursement information from your personal insurance carrier. If the information is not available, assume reimbursement by traditional indemnity insurance is usually 200% reimbursed more than Medicare and Medicaid, and managed care is usually 133% more than Medicare and Medicaid.
Compose an accounts receivable benchmark from this information showing columns for current, 30–60, 61–90, 90–120, and greater than 120 days.
Assess the information for areas of improved reimbursement of at least 20% or more.
Evaluate the options available to change the payer–patient mix with consideration of related legal and ethical issues.
Propose a best strategy with justification and rationale based on effective decision-making tenets.

The body of the resultant paper should be 10–12 pages. Spreadsheets demonstrating the accounts receivable analysis will be attached as appendices, and there will be at least 7 relevant peer-reviewed academic or professional references published within the past 5 years. Also attach appropriate fee schedules.

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