DAVENPORT UNIVERSITY

Final Project Information

HINT 250 Introduction to Reimbursement to Health Information

Maxine White February 18, 2012

As a medical professional, there is a certain set of values, attitudes, and behaviors that should automatically result in serving the interests of their patients and society after all that is why they have chosen that profession. Oftentimes, many of those working in the healthcare profession take pride in caring for their patients health before caring for one's own. Honesty and integrity are values essential to the medical profession. Type the abstract of the document here.
The abstract is typically a short summary of the contents of the document. Type the abstract of the document here.

1. Report on the importance of professionalism in health care and how one identifies a health care professional. Describe characteristics and behaviors that demonstrate a commitment to the profession. Discuss the importance of character, values, morals, ethics and other personal traits. Explain how personal image and personal skills affect ones professional reputation. Identify how you will develop and strengthen professional traits and behaviors to excel in your chosen profession. As a medical professional, there is a certain set of values, attitudes, and behaviors that should automatically result in serving the interests of their patients and society after all that is why they have chosen that profession. Oftentimes, many of those working in the healthcare profession take pride in caring for their patients health before caring for one's own. Honesty and integrity are values essential to the medical profession. The professional healthcare worker has an attitude of humility and accountability to patients, colleagues, and society. Professional behaviors include a nonjudgmental and respectful approach to patients; The attitude helps patients two decide if they will remain committed to organization pursuit of specialized knowledge and skill with a commitment to excellence and life-long competency, and a collegial and cooperative approach to working with members of a healthcare team in the delivery of patient care. Lastly, community service and public leadership reinforce the responsibility of those working in the medical field to fulfill the goals set forth by the profession and the public. In exchange for putting the interests of the patient and public first, healthcare workers are accorded trust, respect, and the confidentiality of patients." Knowing medicine's ethical foundations is another key component in professionalism. ACP's "Ethics Manual, Fifth Edition," published in the April 5, 2005 issue of Annals of Internal Medicine, is a practical and detailed guide for a wide spectrum of commonly encountered ethical issues. Topics include the healthcare/patient relationship, relations with

health care plans, confidentiality, informed consent, reproductive and genetic issues, end-of-life planning, organ transplantation, euthanasia, research ethics and professional responsibilities. In 2002, the "Medical Professionalism in the New Millennium: A Physician Charter" project spelled out 10 commitments that inform medical professionalism. Those commitments:

Professional competence Honesty with patients Patient confidentiality Maintaining appropriate relations with patients Improving quality of care Improving access to care Just distribution of resources Scientific knowledge Maintaining trust by managing conflicts of interest Professional responsibilities Summary of billing processes and procedures including

Summary of billing processes and procedures including A. Content and use of Registration or Encounter Forms, Explanation of Benefits (EOB), Advance Beneficiary Notice (ABN), Remittance Advice (RA), and Participation Contracts, B. The adjudication process for payers and providers, and The completion of each major claim form (CMS1500, CMS1450/UB92/UB04). The billing process is an interaction between the provider and the insurance company (payer). It begins with the office visit. After the provider sees the patient, depending on the service provided and the examination, the doctor creates or updates the patient's medical record. This record contains a summary of treatment and demographic information related to the patient. Upon the first visit, the provider will usually give the patient a diagnosis (or possibly several diagnoses), in order to better coordinate and streamline his/her care. The treatment, diagnosis, and duration of service combine to determine the procedure code that will be used to bill the insurance. The doctor then either provides this information to a medical

coder or other billing specialist. From this, a billing record, either paper (usually on a standardized form called an HCFA) or electronic, is generated. This form includes the various diagnoses identified by numbers from the current ICD-9 manual. This billing record or claim is then submitted either to a clearinghouse that acts as an intermediary for the information (this is typical for electronic billing) or directly to the insurance company. The insurance company (payer) processes the claim. The insurance side of the process begins with testing the validity of the claim for payment. The tests cover patient eligibility for payment, provider credentials, and medical necessity. Upon passing successfully the tests, the payer pays the claim. If a claim fails the tests, the payer rejects the claim and communicates the rejection message to the claim submission source. Upon receiving the rejection message, the provider must decipher the message, reconcile it with the original claim, make required corrections, and resubmit the claim again. This exchange of claims and messages may repeat multiple times until the claim is paid in full. The frequency of rejections, denials, and underpayments is high (often reaching 50%), mainly because of high complexity of claims and data entry errors. Straight Through Billing technology, procedures, and training help manage the billing process to receive all payments on time.

2. One page report outlining the differences between facility (hospital) claims processing and professional (provider) claims processing.

There are several documents which are required by medical office for the smooth functioning of their financial functions and to make the proper accountability of the in source and outsource of the funds which are needed to fund the hospital management. These documents are facility claims processing or affect the professional claims policy. Accounts receivable, accounts payable, petty cash, purchase receipts and other books of inventory records book what is left and how much of inventory need to be purchased. Apart from financial accountability other policies are needed for the efficient functions of the medical office which are policies for the benefit of patient and the staff for example, financial issues related during payment of medical bills have to be accurate with service given to the patient. Payment options need to be examining which facilities and which are not covered under insurance policies. If there are medical benefits provided for low income people the collection from charity and any copayments done on their behalf need to be keep the track of. Thus, the record of hospital funding need to kept assimilating the good functioning of hospital administration.

3. Comparison of the contents of commercial, managed care and federal insurance plans. SUPPLEMENT EXECUTIVE RETIREMENT PLAN (SERP) this is a plan which is devised between organization and important employees of the organization. This plan is generally made for top executives of the company and organizations set aside the funds for their retirement. This is a contractual retirement plan, to apply for this plan the agreement is to be undersigned between an executive and the company. Life insurance policies are purchased by the company on behalf of the executive and all the formalities to the policy are done by company. The policy is customized and helps to save tax also. 401K PLAN It is a plan in which employee since the beginning of its job investing and planning about the retirement and since employs almost reaches the age of retirement and attaining its 59 years 6months of age can start withdrawing the funds for its personal usage. Most of the American citizen follows this kind of plan. This plan also reduces the taxable income and tax is not accumulated from the income till the employee has not withdrawn the amount.

4. Comparison of major payment and reimbursement systems found in the US and two other countries (of the students choice). Suggestions which need to be given to improve patient-payer communication regarding the claim adjudication process the process of billing of payment till the patient pays the bill need to be happening at the patient visit to the health care office not at any other place considered for payment of bills not at any other facility mentioned. Several hospitals are making online appointments receipt so the patient needs to produce original receipt and payment or order number for the proper record. To avoid confusion proper billing and types and amount of cost and services rendered needs to appropriately prescribed and have a patient satisfaction. With completing of the CMS-1500 form, calculation need to be done appropriately how the patient will be going to pay a how much of his insurers need to pay the claims. In US reimbursement plan need to authorize with the hospital and these claims are put forward. If we take the example of another country insurance claims and payment policy we can use India as our example. India has also several medic aim plans with many banking and insurance sectors banking upon these plans. Though in India the plans which activate are not governmental In die the policy holder of plan can claim claims only after pursue of any doses or ailments occur and generally most of the disused or operations also are not covered in the cost of insurance plans. After getting operated need to submit all the medical bills to the department and while reviewing the ailment, medicines the entire claim would get reimbursed by the insurance company.

5. Outline of the different prospective payment systems currently in use in the United States, including a description of the type of diagnostic and procedural groupings used in each PPS (not each individual grouping within each PPS; for example, not looking for a description of each DRG but a description of DRGs in general). The cost and payment systems of the hospital need to be accurate so as how much of costs, patient charges and other issues need to be accumulated so as to define the cost with various insurance services. The prospective payment systems currently in use in the United States, including a description of the type of diagnostic and procedural groupings used in each PPS like in PPS the claims and payments are predefined determined prices which need to be accumulated. Payments through PPS are claim thorough the specified codes mentioned. Different kinds of PPS are Diagnosis Related Group (DRG), Ambulatory Payment Classification (APC), and Current Procedural Terminology (CPT) The claims codes like DRG which refers to Diagnosis-related groups. DRG refers to identify the medicines, cure or the products received by the patient. As there expansion in the health industry begins and lot of care is need and patients are taking deer care wad precision and sophistication so there was need for expansion scope in DRG system. Wad comparative to the mechanisms of one DRG there are several DRG system have been evolved like Medicare DRG, All patient DRG, Severity DRG, Refined DRG all DRGs are custom made according to need, cure, disease of the patient. In this DRG group hospital has segregated their payment mechanism also according to the budget position of hospital also.

6. One page report on the history of Local Medical Review Policies (now called Local Coverage Decisions or LCDs) and four current examples of these LCDs currently active in your geographical location and an explanation of how each of these LCDs is used in the billing and reimbursement practice. Local Medical Review Policies (LMRP), this police are made by the insurance to cover under the Medicare policies. LMRP includes the description of service, specific procedure codes, and for each of these procedures, a list of covered and non-covered diagnostic codes. Medical insurance planning is when the individual require substantial amount to plan the old age. TO have an appropriate retirement planning a sensible and practical approach is required to go ahead with the appropriate planning structure to be followed with good savings and investment plans which gives higher return and without risk. Firstly need to assess what would be need during tenure and how much monthly deposited so that it can make good lump sum amount in the future. It would be a sort of social security at the old age when we require for medical expenses to be bear. To look for an appropriate and the complicated medical benefits need to look for the medical complexities a medical plan considers. The percentage of the cost bear by this medical insurance company and to look for the other benefitted endowment policies.

7. Report on HIPAA Privacy Rule and its impact on insurance claims processing, including electronic forms defined and contents of each as part of mandatory electronic data interchange (EDI) (including 835 and 837 for example). Health Insurance Portability and Accountability Act (HIPAA), actually works in protection the records of the patients electronically also mention like electronically protected health information. HIPAA is kind of security rule to provide electric patients health information (EPHI) security data. HIPAA is covered under the federal security agencies. The impact of HIPAA on insurance claims processing like Health care provides having tailor made health plans according to the needs of the patient and HIPAA keeps the record of everything related with patients even the prescription and number of visits to the clinic or health centre with the ailments all the issues related with medical history of the patient it contains all the database. HIPAA is used by many structural hospitals so that the all the medical history and its diagnosis been properly understand by the medical practitioners for the further treatment of the patient. The contents are processed in the format of Electronic Data Interchange as the evaluation strategy for the database need to be evaluated with several questionnaires and checklist. Data need to be stored appropriately so that it cannot be reused by unauthorized person for wrong usage. Reusable removable data processing system need to be used. Proper verification of the database along with individual who check the record need to be verified appropriately. Though the machine at times also get out of work so the retrievable copy of the data needs to be kept. Its like backup files need to be kept as the security.

8. Comparison of the classifications, taxonomies, nomenclatures, terminologies and clinical vocabularies used in insurance claims processing. Include definition, required format, and use of each. Current Procedural Terminology (CPT) Coding system of procedures and services Health Common Procure Coding system Used to identify services not mentioned in CPT Clinical Data Interchanges Standard Consortium (CDISC) development of lab data Digital Imaging and Communications in Medicine (DICOM) diagnosis through digital images. Logical Observations Identifiers Names and Codes (LOINC) National Council for Prescription Drug Programs National Uniform Billing Committee International Health Terminology Standards development Organization Health Level 7 ICD-9 CM coordination and Maiantannee Committee - International Classification of Diseases A Medicaid management information system (MMIS) is a mechanized system of claims processing and information

9. A report describing the role of the Office of Inspector General (OIG) in coding compliance, auditing and reporting. Select two audits from the current OIG Work Plan and describe the focus and intent of each of these audits. Office of Inspector General (OIG) procedures which need to be compliant with the financial policies and need to be supported by the office are like 1. Appropriate and suitable conditions to be formed for the payment policies which need to

be collected from the patients. 2. 3. Practicing of the follow up to be considered while practicing late payments module. Cycle of billing and payment to be reduced as per the visit of the patients for the regular

and official visit to hospital for check-up and further prognosis. 4. The policies should mentions what form of payment need to be accepted by the hospital

like whether the payment would be in form of cash, any card whether debit or credit to be accepted. Office of Inspector General (OIG) should keep the accountability of accidents charges and insurance payments related with the accidental charges etc. 5. Also to need the record of any fraudulent policies whether the medical office or any staff

is not practicing the embezzlement of funds so the policies need to be framed with the understanding of the patient.

10. Report on your states Quality Improvement Organization (formerly Peer Review Organization). Describe the history of the organization, current Medicare projects, and services, projects and initiatives offered to others within the healthcare industry. Help and Human Services (HHS) is a department who organizes program initiated by USA government and also for states. The organization main objective is to care about the health of the citizens of America and also provide them at the affordable rate. HHS is largest insurer of the federal and claims nearly more than 1 millions claims. It covers nearly 300 programs under its belt for benefit of the citizens. The conclusions while understanding the budget prospects it is ascertained that there are health reforms are needed the reform need to reduce the level of cost involved in medical expenses. As the heath care costs are very expensive so these costs also need to be reduced so that they dont amount any amount of debt on the people. Patients need to choice what kind of health plan they will take to opt for in respective of the physician. Need to focus on health of patient with quality care benefits. Inferences we can draw with the services and monetary benefits provided by US government for its citizens is a commendable task and most of the people are also benefitted by this program. Government offers this program to all the citizens irrespective of any discrimination. The budget which is very high is allocated to provide expensive drugs at the affordable rates to the patients. As several and numerous incongruous disease available, so to allocate medical centers with newest state of technology to detect the patient condition and disease and apart from this program it helps to provide several vaccination programs throughout the country to protect citizens from pandemic diseases.

11. Report on the importance of professionalism in health care and how one identifies a health care professional. Describe characteristics and behaviors that demonstrate a commitment to the profession. Discuss the importance of character, values, morals, ethics and other personal traits. Explain how personal image and personal skills affect ones professional reputation. Identify how you will develop and strengthen professional traits and behaviors to excel in your chosen profession. External environment is the entity which engrossed the environment and determines the uncertainties which underlines the posterity who paved for the factors that changed the environment of the organization stupendously. In context to health care management the external factors which change the working conditions within the organization are at times the preference of patients changes with times if the hospital maintence is unkempt so the patient would move for another hygienic place. Most important factor is availability of skilled doctors and medical professionals if they are not available and most important is this part leads to life of patients so availability of skilled work force is very important. Among the newest technology according to rules and regulations should be used for the treatments and diagnosis of medical conditions of patients. Role of medical practitioner and the Board of health care organization is responsible for whole health care administration. Directing, recruiting and retention of the staff are its major responsibility. Assurances whether the medical treatments and the standard are perceived are according to module prescribed and with appropriate compliance policy also. The environment should be created should be work friendly and understand the facilities and benefits to be provided to staff and patients so that no extra burden do not ascertain with the allocation of budgeting cost of health care.

12. Report on the role of the Federal Register in the insurance claims processing profession. Give examples of current proposed and final rules that may affect the profession. There are several rules and regulations mentioned in the Health Information policies mentioned in the Health Register all the rules changed rulese modified rules mentioned in the Federal register. several expenses to develop and produce routine and low risk software so its research expenses wont be considered into a taxable income and tax credit is about to introduce in formalizing this company software project. The Valuation process on the basis of Average Present Value and WACC method in determine the value of the company. 1. The asset arising from research should not be recorded as an asset and therefore research

cost of internal project should be considered as an expense in financial statements. 2. The technical feasibility, product availability for sale and quality, future revenues derived

to cover cost should be considered. 3. Operational expenses like salaries, inventory and overhead should be considered and

included for evaluation. 4. 5. Selling and administration along with losses should not be considered. Exact method of depreciation and amortization should be considered and mentioned

appropriately.

References -: 1. Iglehart JK. The new era of prospective payment for hospitals. N Engl J Med 1982; 307:12881292 Budgetry Control A Behaviour, A Andrew C Stedry, 2001, Oxford Publishing, Budgetry Control and Standard Costs, John Agnus Scott, 1970, Leisure Manager's Guide to Budgeting and Budgetary Control by Simon Shibli and Dawn Robbins (Spiral-bound - Jan. 10, 1995