Introduction:
Health informatics professionals play an important role in the health informatics and information management (HIIM) team in the area of coding management and reimbursement processes. The federal
government’s Centers for Medicare and Medicaid introduced quality reporting systems to link financial rewards to the provision of quality healthcare. The legal and regulatory systems that impact work processes in
HIIM and throughout healthcare organizations are specific in their mandates: healthcare organizations and providers will adhere to the law to prevent legal consequences.
Task:
Create a multimedia presentation (suggested length of 12-15 slides) in which you do the following:
Note: Your multimedia presentation may use various forms of visual aids and organizational patterns (e.g., charts, graphs, tables).
A. Discuss the quality reporting systems sponsored by Centers for Medicare and Medicaid Services (CMS) by doing the following:
- Discuss the goals of quality reporting systems in healthcare organizations.
- Compare the advantages and disadvantages of quality reporting systems.
- Compare different quality reporting systems models currently used.
- Illustrate the role of HIIM staff in participating in value-based purchasing as one of the quality reporting systems.
B. Present important legal points pertaining to compliance and reimbursement by doing the following:
- Illustrate how the False Claims Act pertains to healthcare providers.
- Summarize the criminal statutes regarding Medicare funding.
a. Illustrate how specific criminal statutes regarding Medicare funding pertain to healthcare providers.
- Compare the Sherman Act, the Clayton Act, and the Federal Trade Commission Act.
a. Discuss the importance of these acts to healthcare providers.
- Compare Stark II and the anti-kickback statute of the Medicare and Medicaid Protection Act of 1987.
a. Discuss the importance of these statutes to healthcare providers.
C. When you use sources, include all in-text citations and references in APA format.
Note: When using sources to support ideas and elements in a paper or project, the submission MUST include APA formatted in-text citations with a corresponding reference list for any direct quotes or
paraphrasing.Include weblinks for all sources. It is not necessary to list sources that were consulted if they have not been quoted or paraphrased in the text of the paper or project.
Note: No more than a combined total of 30% of a submission can be directly quoted or closely paraphrased from sources, even if cited correctly.
Introduction
Health informatics professionals – part of
HIIM team.
Very vital role- reimbursement and coding
management processes.
Quality reporting systems- link financial
rewards and quality healthcare provision.
Regulatory and legal systems- strict
adherence to the law (Slade, 2000).
Goals of quality reporting systems
Summarizing data
Tracking performance (Inside the Minds, 2012).
Availing comparative data
Evaluation and reporting on quality data-
system-wide improvements.
Promoting accountability
Facilitating QI- proper data interpretation.
Advantages of quality reporting systems
Streamlining quality reporting programs.
Reduced burden on hospitals.
Quality care improvement (Carrier & Cross,
2013).
Single sets of electronic specifications.
Adoption of data standards.
Disadvantages of quality reporting
systems
Choosing kinds on quality indicators.
Coming up with risk-adjusted
methodologies.
Availability of data.
Defining quality and what to collect.
Hospital costs (Tremaine & Homchick,
2010).
Quality reporting systems models
Value-based purchasing (VBP)
Employers- use market power to promote value
and quality.
Overarching goal- healthcare system founded on
value.
How purchasers use purchasing power.
Purchasers can hold providers responsible for
quality and cost.
Brings together healthcare quality information.
Value-based purchasing (VBP)
cont’
Focuses on health care system management
Major elements;
Reporting and measuring comparative
performance (Federal Trade Commission,
2013).
Different pays for providers based on
performance.
Developing health benefit incentives and
strategies
Value-based benefit design
(VBBD)
Purchasers pursuing value-based purchasing.
Explicit utilization of plan incentives.
Proper high value services use.
Healthy lifestyle adoption.
Using high performance providers.
Goes beyond the insurance realm.
Value-based insurance design (VBID)
Purchasers pursuing value-based purchasing.
Based on copayments of patients .
Cost sharing, and mitigating adverse health impacts
Medical services and certain intervention’s value
differ.
Focuses on financial disincentives and incentives
Aligning insurance with consumer health behavior’s
goals (Value-Based Purchasing, 2011).
Role of HIIM staff in value- based purchasing
Improving quality and cost.
Minimize inappropriate care.
False Claims Act
Liability ion providers- unbundling, upcoding,
billing ghost patients, and billing for
unnecessary or insufficient care.
Remedy for government.
Powerful civil weapon.
Used for investigating various providers.
Entities for assisting in transactions.
Criminal statutes
False Claims Act
Prevents false claims demanding for
compensation.
False Statements Act
Specializes in fraudulent or false statements or
documents in communications.
Criminal statutes cont’
Anti-Kickback Statute
Prevents soliciting, paying, offering, or
receiving any compensation.
Federal Mail and Wire Fraud
Utilizing communications forms in deceptive
activities.
Physician self-referral law
Making referrals in cases where there are
compensation agreements.
Sherman Act, the Clayton Act, and the
Federal Trade Commission Act
3 cardinal federal antitrust laws.
Sherman Act
Outlaws conspiracy in trade restraint (California
Healthcare Foundation, 2002).
Controls monopolization.
Promotes healthy competition.
Prevents plans to divide markets or rig bids.
Punishment- fines and imprisonment.
The Clayton Act
An extension of the Sherman Act.
Promotes healthy competition (World Health
Organization, 2006).
Prevents monopoly.
Bans discriminatory acts from merchants.
Protects private companies.
The Federal Trade Commission
Act (FTC)
Bans unfair competition strategies.
Prevents deceptive acts.
Violations same as in Sherman Act.
Activities punishable in Sherman Act and
FTC.
Stark II statute
physicians should not make referrals to
entities where providers have investment
interest or ownership (Rubin, Pronovost &
Diette, 2012).
Entities- compensation agreements.
Anti-Kickback statute
Makes it a criminal misdemeanor to knowingly
receive or make compensation to offer a service
reimbursable by a federal program (Bennett,
2012).
The two statutes- providers- no financial links.
References
Bennett, M. L. (2012). Criminal Prosecutions For Medicare And Medicaid
Fraud. Retrieved on 13th
February, 2014 from
http://www.aapsonline.org/fraud/fraud.htm
California Healthcare Foundation. (2002). Creating a state-wide hospital
quality reporting system.
Retrieved on 13th February, 2014 from
http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/
C/PDF%20CreatingHospitalQualityReporting.pdf
Carrier, E., & Cross, D. (2013). Hospital Quality Reporting: Separating the
Signal from the Noise.
Retrieved on 13th February, 2014 from
http://www.nihcr.org/Hospital-Quality-Reporting
Federal Trade Commission. (2013). The antitrust laws. Retrieved on 13th
February, 2014 from
http://www.ftc.gov/tips-advice/competition-guidance/guide-antitrust-
laws/antitrust-laws
Inside the Minds. (2012). Managing health care transactions. Retrieved on
13th February, 2014 from
http://www.fowlerwhite.com/docs/TayonChapter2012.pdf
References cont’
Rubin, H. R., Pronovost, P., & Diette, G. B. (2012). The advantages and disadvantages
of
process-
based measures of health care. International Journal for
Quality in
Health Care,
13(6): 469-
474.
Financial Resource
Management and
Healthcare
Reimbursement
Introduction:
Health informatics professionals play an important role in the health informatics and information management (HIIM) team in the area of coding management and reimbursement processes. The federal
government’s Centers for Medicare and Medicaid introduced quality reporting systems to link financial rewards to the provision of quality healthcare. The legal and regulatory systems that impact work processes in
HIIM and throughout healthcare organizations are specific in their mandates: healthcare organizations and providers will adhere to the law to prevent legal consequences.
Task:
Create a multimedia presentation (suggested length of 12-15 slides) in which you do the following:
Note: Your multimedia presentation may use various forms of visual aids and organizational patterns (e.g., charts, graphs, tables).
A. Discuss the quality reporting systems sponsored by Centers for Medicare and Medicaid Services (CMS) by doing the following:
- Discuss the goals of quality reporting systems in healthcare organizations.
- Compare the advantages and disadvantages of quality reporting systems.
- Compare different quality reporting systems models currently used.
- Illustrate the role of HIIM staff in participating in value-based purchasing as one of the quality reporting systems.
B. Present important legal points pertaining to compliance and reimbursement by doing the following:
- Illustrate how the False Claims Act pertains to healthcare providers.
- Summarize the criminal statutes regarding Medicare funding.
a. Illustrate how specific criminal statutes regarding Medicare funding pertain to healthcare providers.
- Compare the Sherman Act, the Clayton Act, and the Federal Trade Commission Act.
a. Discuss the importance of these acts to healthcare providers.
- Compare Stark II and the anti-kickback statute of the Medicare and Medicaid Protection Act of 1987.
a. Discuss the importance of these statutes to healthcare providers.
C. When you use sources, include all in-text citations and references in APA format.
Note: When using sources to support ideas and elements in a paper or project, the submission MUST include APA formatted in-text citations with a corresponding reference list for any direct quotes or
paraphrasing.Include weblinks for all sources. It is not necessary to list sources that were consulted if they have not been quoted or paraphrased in the text of the paper or project.
Note: No more than a combined total of 30% of a submission can be directly quoted or closely paraphrased from sources, even if cited correctly.
Introduction
Health informatics professionals – part of
HIIM team.
Very vital role- reimbursement and coding
management processes.
Quality reporting systems- link financial
rewards and quality healthcare provision.
Regulatory and legal systems- strict
adherence to the law (Slade, 2000).
Goals of quality reporting systems
Summarizing data
Tracking performance (Inside the Minds, 2012).
Availing comparative data
Evaluation and reporting on quality data-
system-wide improvements.
Promoting accountability
Facilitating QI- proper data interpretation.
Advantages of quality reporting systems
Streamlining quality reporting programs.
Reduced burden on hospitals.
Quality care improvement (Carrier & Cross,
2013).
Single sets of electronic specifications.
Adoption of data standards.
Disadvantages of quality reporting
systems
Choosing kinds on quality indicators.
Coming up with risk-adjusted
methodologies.
Availability of data.
Defining quality and what to collect.
Hospital costs (Tremaine & Homchick,
2010).
Quality reporting systems models
Value-based purchasing (VBP)
Employers- use market power to promote value
and quality.
Overarching goal- healthcare system founded on
value.
How purchasers use purchasing power.
Purchasers can hold providers responsible for
quality and cost.
Brings together healthcare quality information.
Value-based purchasing (VBP)
cont’
Focuses on health care system management
Major elements;
Reporting and measuring comparative
performance (Federal Trade Commission,
2013).
Different pays for providers based on
performance.
Developing health benefit incentives and
strategies
Value-based benefit design
(VBBD)
Purchasers pursuing value-based purchasing.
Explicit utilization of plan incentives.
Proper high value services use.
Healthy lifestyle adoption.
Using high performance providers.
Goes beyond the insurance realm.
Value-based insurance design (VBID)
Purchasers pursuing value-based purchasing.
Based on copayments of patients .
Cost sharing, and mitigating adverse health impacts
Medical services and certain intervention’s value
differ.
Focuses on financial disincentives and incentives
Aligning insurance with consumer health behavior’s
goals (Value-Based Purchasing, 2011).
Role of HIIM staff in value- based purchasing
Improving quality and cost.
Minimize inappropriate care.
False Claims Act
Liability ion providers- unbundling, upcoding,
billing ghost patients, and billing for
unnecessary or insufficient care.
Remedy for government.
Powerful civil weapon.
Used for investigating various providers.
Entities for assisting in transactions.
Criminal statutes
False Claims Act
Prevents false claims demanding for
compensation.
False Statements Act
Specializes in fraudulent or false statements or
documents in communications.
Criminal statutes cont’
Anti-Kickback Statute
Prevents soliciting, paying, offering, or
receiving any compensation.
Federal Mail and Wire Fraud
Utilizing communications forms in deceptive
activities.
Physician self-referral law
Making referrals in cases where there are
compensation agreements.
Sherman Act, the Clayton Act, and the
Federal Trade Commission Act
3 cardinal federal antitrust laws.
Sherman Act
Outlaws conspiracy in trade restraint (California
Healthcare Foundation, 2002).
Controls monopolization.
Promotes healthy competition.
Prevents plans to divide markets or rig bids.
Punishment- fines and imprisonment.
The Clayton Act
An extension of the Sherman Act.
Promotes healthy competition (World Health
Organization, 2006).
Prevents monopoly.
Bans discriminatory acts from merchants.
Protects private companies.
The Federal Trade Commission
Act (FTC)
Bans unfair competition strategies.
Prevents deceptive acts.
Violations same as in Sherman Act.
Activities punishable in Sherman Act and
FTC.
Stark II statute
physicians should not make referrals to
entities where providers have investment
interest or ownership (Rubin, Pronovost &
Diette, 2012).
Entities- compensation agreements.
Anti-Kickback statute
Makes it a criminal misdemeanor to knowingly
receive or make compensation to offer a service
reimbursable by a federal program (Bennett,
2012).
The two statutes- providers- no financial links.
References
Bennett, M. L. (2012). Criminal Prosecutions For Medicare And Medicaid
Fraud.
California Healthcare Foundation. (2002). Creating a state-wide hospital
quality reporting system.
Carrier, E., & Cross, D. (2013). Hospital Quality Reporting: Separating the
Signal from the Noise.
Federal Trade Commission. (2013). The antitrust laws.
Inside the Minds. (2012). Managing health care transactions.
References cont’
Rubin, H. R., Pronovost, P., & Diette, G. B. (2012). The advantages and disadvantages
of
process-
based measures of health care. International Journal for
Quality in
Health Care,
13(6): 469-
474.