4-1 Short Paper_ Payment Systems
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Apr 3, 2024
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4-1 Short Paper: Payment Systems
Kelly Gray
Healthcare Reimbursement
With regard to the service that is given to patients, it is crucial to include all of the
proper and accurate documentation that is required. The most important information consists of things like proper CPT codes, up to date insurance, the demographics of a patient, and a patient’s diagnosis. Different from some other organizations, the healthcare field has particular rules and regulations that have to be followed every day in order to stop issues with reimbursement problems, lawsuits and injuries to patients. The reason for
this is because healthcare reimbursement is is one of the main processes that is needed for finalized appointments, and to make sure the payment is made in full so services that are administered to patients are accounted for and fully paid. To make sure of this, healthcare organizations have to follow the protective payment system. On the basis of
managing capital related costs of diagnosis, and regulates reimbursement for patient care that is appointed to medicaid and medicare recipients. There are 3 different things that are included in the coding and billing process and they are HCPCS, DRG’s, and CPT’s. DRG’s classify certain diseases in the system of billing in order to see what is needed for the right kind of care a patient may need. When billing clerks bill under the inpatient payment system, it lets the reimbursement and its costs become controlled. Nowadays DRG’s are used mostly for impatient visits. When this occurs, Medicare reimburses the healthcare organization and it depends on the CPT codes that are being used, a patient’s diagnosis, and the DRG. Medical billing codes are used for making claims for insurance and billing patients for further services. Coding consists of using information from billing to get facts and figures from documentation and medical records to finish claims. In healthcare these sets of symbols are known as current procedure terminology. These codes keep order of the of the healthcare services that are being billed by the providers, and they also regulate the sum of reimbursement awarded and how much the patient’s have to recompense, for the received services. Healthcare common procedure codes is a way that healthcare organizations and billing clerks use to forward claims to the payers like commercial payers, medicare, and state insurance. On the authority of the AAPC, the government came up with the idea for coding in order to standardize the details of services to the government so they can be reimbursed. HCPS’s utilize two different level sets, one and two. The variations between both levels is that level one uses the CPT codes that can be used to send the claims for
healthcare organizations, clinics, nursing homes, physicians, and hospitals. Level 2 codes include the processes and any type of medical equipment that may have been used. Overall, there is a great deal that pours into a medical payment system. Coding and billing both have a lot of regulations to make sure all of the information is correct. It is
very important that the billing process is completed accurately to steer clear of things happening such as distress and lawsuits. It is also very important that healthcare providers receive proper reimbursement for all of their services.
References Roland-Jenkins, T., PhD. (2023, August 24). Insurance reimbursement challenges
for physicians. MPR. https://www.empr.com/home/ppl/insurance-reimbursement-
challenges-for-physicians/
Arora, V. M., Moriates, C., & Shah, N. (2015). The challenge of understanding
health care costs and charges. AMA Journal of Ethics, 17(11), 1046–1052.
https://doi.org/10.1001/journalofethics.2015.17.11.stas1-1511
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