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Medicare, Medicaid, and Managed Care
Beth Doeden
Capella University
MHA-FPX5006
Hlth Care Fin & Reimbursement
June 27, 2022
2
Prepared is information that reviews three types of familiar revenue sources, Medicare,
Medicaid, and Managed Care, and what they are.
I will be checking what each program is, how
to be reimbursed, what reimbursement will look like, and what the benefits are to each program.
Medicare
Medicare is a government program offered to those 65 years of age or older and those
with disabilities.
Currently, there are 60 million beneficiaries, with 51.2 million aged 65 and
older and 8.8 million with disabilities.
Medicare is offered in two parts, A and B.
Medicare
part A covers inpatient admissions and the services and supplies that go with them.
Part A also
includes a limited amount of coverage for skilled nursing facilities.
Part B covers outpatient
services, physician visits, lab, diagnostics services, therapies, and ambulance care (Medicare
Primer, 2022).
Medicare beneficiaries also can receive their Medicare part A and B via a private
Medicare part C, also called Medicare Advantage.
MA is offered through a private insurance
company and presents additional benefit packages to assist healthcare needs such as vision and
dental (Medicare Primer, 2022).
There is also prescription drug coverage through private
insurance plans called Medicare Part D.
Reimbursement for Medicare claims is often lower than traditional private insurance.
In
some instances, it is up to the provider to cover the costs of these overages.
For that reason,
some providers will not accept Medicare patients.
Yet, not accepting Medicare patients excludes
a very large demographic of patients.
These providers who participate are called "accepting
assignment" providers and have signed a contract with Medicare agreeing to accept all of
Medicare's predetermined costs (Medicare.org, 2022).
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To be paid on a Medicare claim, an itemized list of services and supplies need to be
submitted,
Non-participating providers, meaning providers who have not signed a contract with
Medicare to accept their prices, are providers who may accept Medicare payment but will require
additional payment upfront.
Reimbursement for Medicare Part A requires 24 hours of inpatient stay.
Less than that
would be considered outpatient or overnight observation and covered under Medicare Part B.
Medicare will pay 80% of the stay once the deductible has been met.
The Inpatient Prospective
Payment Systems is utilized which uses diagnostic related groups (DRGs) to group inpatient
admissions into categories that look at the average cost of resources that specifically treat the
ailment or diagnosis (Medicare.gov, 2022).
Once these claims have been submitted, it could take
a week to 60 days for review and payment.
Reimbursement for Medicare Part B is based on outpatient provider care.
Clinics will
submit a claim directly to Medicare, and the costs associated with an office visit, for instance,
will be reimbursed based on the patient's coverage.
Information such as diagnosis, date of
service, referral information, provider notes, and service levels will be submitted for
reimbursement.
This is based on the fee schedule and if the provider is an "accepted assignment"
or if they participate in Medicare.
This, too, can take at least 60 days (Medicare.org, 2022)
Medicare is an excellent option for our older adults and our healthcare organizations to
keep the cost of care down and bring in a steady stream of reimbursement.
Medicaid
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Medicaid is a program that provides healthcare coverage to low-income adults, children,
pregnant people, the elderly, and those with disabilities.
Funds are provided by both state and
federal governments and managed by the state, corresponding to federal requirements
(Medicaid.org, 2022).
Medicaid provides access to care that otherwise would not be affordable.
For instance, Minnesota's Medicaid program (Medical Assistance or MA) uses a sliding scale
based on family size, income, age of children, and assets.
(MN.GOV, 2014)
Reimbursement for MA services is based on a fee for service, which pays a flat rate of
services delivered and is reimbursed at the lowest rate.
Services are submitted through the
patients’ healthcare organization and are paid based on their fee for service and the patient's
responsibility if there is any.
Therefore, Medicaid patients have the lowest rate of accepted
patients to private practices.
Claims cannot be submitted any later than 12 months from services
rendered.
Information including notes, diagnosis, orders, referral information, and level of
services may be needed to cover the costs.
Once claims are submitted, it could be anywhere
from a week to 3 months for a claim to be paid, depending upon the information presented
(Medicaid.org, 2022),
Medicaid is beneficial to healthcare organizations as it guarantees payment and gives
providers a large population to draw from.
Patients also get the care they need at a cost they can
afford (HRF, 2022).
Managed Care
Managed Care delivery systems work to manage the quality and cost of medical services
received (Health Insurance.org, 2022).
Systems use HMO, EPO, PPO, or POS to limit access to
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certain providers and if the provider is out-of-network.
Managed Care generally focuses on
prevention and improved quality of health.
Managed Care reimbursement has a unique approach to reimbursement.
First, the highest
reimbursement is usually for preventative services such as physicals and immunizations.
Managed Care focuses on value-based care and prevention to reduce healthcare costs and better
forecast future impact on reimbursement (
PayrHealth, 2022
).
Many healthcare organizations are
paid based on the Managed Care contracts and have benchmarks they are measured on, which
will determine their rate of reimbursement.
For instance, there could be outcomes based off
blood pressure reduction rates, and reimbursement from the managed care contract will be based
if the organization has met that benchmark.
Quality of care is directly tied to the reimbursement
from those contracts.
Using a metric performance will determine the initial rate of
reimbursement and the potential end-of-year payouts.
Managed health benefits the patients by keeping on top of their wellness to prevent future
ailments or chronic diseases.
Healthcare organizations are helped by keeping their quality-of-
care top-notch and driving down costs.
I hope this provides a better understanding of Medicare, Medicaid, and Managed Care
and how it affects our providers, patients, and reimbursement.
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References:
Health Insurance.org. (2022). Retrieved from
managed care - healthinsurance.org
Healthline. (2022). Retrieved from
Understanding Medicare Reimbursement & Claims (healthline.com)
HRF. (2022).
Retrieved from
8 Pros and Cons of Accepting Medicaid - HRF (healthresearchfunding.org)
Medicaid.gov. (n.d.). Retrieved from
National Medicaid & CHIP Program Information | Medicaid
Medicare.org. (2022). Retrieved from
How Does Medicare Reimburse Hospitals? | Medicare & Medicare Advantage Info, Help
and Enrollment
MN Department of Human Services. (2016, Aug 16). Retrieved from
Program overviews / Minnesota Department of Human Services (mn.gov)
MN Department of Human Services. (2014, April 5). Retrieved from
Medical Assistance (MA) / Minnesota Department of Human Services (mn.gov)
National Academy of Social Insurance. (2020. Mar). Retrieved from
Medicare-Primer.pdf (nasi.org)
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PayrHealth. (2022). Retrieved from
How Managed Care Contracts Impact Reimbursement | PayrHealth