Issues and Trends in HBI Ch20 pp

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Issues and Trends in HBI Ch20 pp

  1. 1. Handbook of Informatics for Nurses & Healthcare Professionals Fifth Edition CHAPTER 20 Regulatory and Reimbursement Issues Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  2. 2. Learning Outcomes1. Know which agencies govern the regulation of reimbursement for medical services at the federal, state, and local levels.2. Demonstrate a basic understanding of Medicare Parts A, B, and C, and Medicaid. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  3. 3. Learning Outcomes3. Recognize the impact that Electronic Data Interchange (EDI) has had on the healthcare delivery system and the role that informatics nursing has played.4. Discuss the ramifications of the Pay- For-Performance legislation, its pros and cons, and possible stumbling blocks. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  4. 4. Learning Outcomes5. Delineate potential problems and benefits involved in the transition to the ICD-10 and what will occur during the transition period.6. Articulate a basic knowledge of billing codes and their affect upon reimbursement amounts, rejections, and appeals. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  5. 5. Learning Outcomes7. Appraise the impact that changes in Medicare physician payment in reimbursement and the expansion of the "do not pay" list will have on the healthcare delivery system.8. Discuss the impact of the new regulatory and reimbursement laws passed in 2009−2010 on system use and design and when they will be integrated into the system. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  6. 6. Learning Outcomes9. Comprehend the financial incentives for implementing technology, and the impact of the adoption of certified Electronic Health Records (EHR) systems on Medicare reimbursement procedures.10.Explore the role of the informatics nurse in strengthening the meaningful use of EHR systems. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  7. 7. Regulatory Agencies• Regulatory agencies are public authorities or government agencies responsible for exercising authority over some area in a regulatory or supervisory capacity.• Health insurance regulation is visible at every government level.• Each state determines how it will fill this regulatory role mandated at the federal level. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  8. 8. Regulatory Issues• The ability to access sensitive health information in electronic patient records by many different sources generates growing concerns over privacy and confidentiality. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  9. 9. Medicare and Medicaid• Medicare Part A, B, C, D• Medicaid eligibility is determined by income. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  10. 10. State Health Departments• Schools• Mental health facilities• Rehabilitation hospitals Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  11. 11. Reimbursement Issues• Medicare, Medicaid, and other third- party payers dictate reimbursement criteria.• Documentation is key to documenting the need for service and reimbursement. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  12. 12. Reimbursement Issues• Automated systems enhance the quality of documentation, which can improve reimbursement, track claims status, report denials, and shorten the revenue cycle. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  13. 13. ICD-10-CM codes• Based on World Health Organization’s International Classification of Diseases Ninth Revision• System of codes for diagnoses and procedures• Provide reimbursement for services delivered in outpatient areas Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  14. 14. Healthcare Common Procedure Coding System (HCPCS)• Level I (Current Procedural Terminology [CPT])—numeric system used for services and procedures furnished by physicians and other providers, maintained by the AMA• Level II—products, supplies, durable medical equipment, prosthetics, and orthotics Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  15. 15. Healthcare Common Procedure Coding System (HCPCS)• Medicare and Medicaid services maintain and distribute HCPCS Level II codes Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  16. 16. Changes in Reimbursement• Expansion of the “Do Not Pay” List for preventable complication Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  17. 17. Adoption of EHR• Medicare reimbursement• Meaningful use of EHR Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  18. 18. Future Directions• Decreased reimbursement will lead providers to turn more to information technology to increase their efficiency. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar

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