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THE ESSAY

Journal: Compliance, Coding, and Reimbursement

Reimbursement Concepts

There were numerous billing and coding regulations that affect health care reimbursement discussed. These guidelines are put in place to help protect the patients and make sure that there is fair legal health care treatment. One of the biggest impacts in every aspect of healthcare is the Health Insurance Portability and Accountability Act (HIPAA). This act applies to certain provisions for coding and billing for "all health plans, healthcare clearinghouse, and to any health care providers who transmits health information in electronic form in connection with transactions," to include financial and administrative transactions," for which the Secretary of HHS has adopted standards under HIPAA" (HHS, 2017).One of the goals of HIPAA was to implement a standardized electronic data interchange between the health care provider and the insurance company, a government agency such as CMS, and other agencies providing services or products for the patient. HIPAA mandates that every provider who does business electronically and all parties involved in these interchanges use the same health care transactions, code sets, and identifiers (HHS, 2017). The Prospective Payment Systems (PPS) reimburses hospitals according to the Diagnosis Related Groups (DRGs). Reimbursement is based on several factors including third-party payers, health care providers, coding and data, and the software used to input data (Harrington, 2016, p 137). Documentation must be accurate and detailed to include the patient's past health history and symptoms at admission to receive full reimbursement through DRG payment. Overall, PPS shifts the responsibility of profit or loss from the insurance company to the health care provider.

With this payment system, it is based on averages and grouping patients in similar groups, the health care facility must make a profit now based on the averages and managing care to give the highest quality of care possible.

The Affordable Care Act (ACA) is another regulation that affects health care reimbursement. The ACA is a health care reform law that was enacted in March of 2010 and had three primary goals. These goals were to make health insurance more affordable and available to everyone, expand the Medicaid program to cover adults with income below the federal poverty level, and support innovative medical care that will lower the costs of health care (U.S. Department of Health and Human Services).

The ACA is committed to shifting health care from a volume-based reimbursement system to a quality-based reimbursement system. This means they want patients billed based on the value of the health care of their outcome. With Medicare transforming over to the PPS system in the 1980s, it increased patient numbers, as health insurance was more affordable now and easier to get.

Unfortunately, health care facilities' reimbursement rates were lower for major events like surgeries, trauma, and hospital admissions. This was really putting a strain on the health care industry. The ACA pushed and promoted primary care physicians and facilities which allowed the primary care industry to grow under the ACA. Since the ACA was promoting primary care physicians so much more, they were getting paid less money, they were scared that the ACA was going to ask them to expand their services and still get paid at the same level of reimbursement.

Assess the impact of regulations on reimbursement in a health care organization and explain what you think is working and what could be a challenge. If possible, bring in a real-world example from your life or from something you have read about.

Coding and billing regulations are directly affected by the ACA. Packaging is referred to as items and services that are necessary to complete treatment, and are combined for billing.

For example, routine supplies, anesthesia, recovery room use, and most drugs are considered to be an integral part of a surgical procedure, so payment for these items are packaged into the APC payment for the surgical procedure" (Harrington, 2016, p. 196). Coding staff must understand packaging and its role within the Hospital Outpatient Prospective Payment Systems (OPPS). There are so many kinds of packaging that can be done and if it is done incorrectly, certain packages won't be reimbursed. Services that aren't reimbursed because of incorrect coding can mount up and become a real financial burden to the organization. These regulations are implemented to protect patients and ensure health care follows the correct guidelines set forth to provide quality care.

HIPAA protects crucial information belonging to the patient that allows their conditions, identity, and treatments to remain confidential (HHS, 2017). The ACA allows health care coverage to be more affordable and available to a larger variety of people. Supposedly, these regulations work to provide the highest quality of care at affordable rates for all patients. I think that these regulations need to be reevaluated. It almost feels like the ACA is directing how our physicians take care of us instead of allowing them to take care of us. How does the ACA know that something is necessary to complete treatment? Just because it is that way for the majority of people doesn't mean it is that way for everyone. The ACA is supposed to be making insurance more affordable but for the middle-class family that doesn't have insurance through their work, the ACA is priced outrageously. That is speaking from first-hand experience. I just went without insurance because I couldn't afford it. It was cheaper for me to pay the tax penalty than to get insurance through the ACA. I also think that the facilities need to ensure that the people doing their coding and billing are well trained.These are such important jobs because basically, they hold the whole financial security of the facility in their hands. Ensure they have a proper work schedule, appropriate time off, and breaks to keep them alert so they will make fewer errors. Everyone is going to make a mistake at some point because we are not perfect but ensuring those few things will help cause fewer errors. I have never had the experience of working in a physician's office but I do work on an ambulance and if I don't get every patients information down correctly and I don't fill in all the proper information and narrative so that the billing department can tell what kind of coding needs to be done for the billing then I am not doing my job to the best of my ability and I wouldn't have it long. So, in a sense, all the people a patient sees in the physician's office is in for accurate information that generates clean claim.