The Consortium for Citizens with Disabilities (CCD) submitted comments on interim final rules implementing provisions of the Affordable Care Act regarding coverage of preventive services. CCD supports coverage of preventive services without cost sharing but believes rules should be strengthened. CCD recommends expanding the definition of preventive services and medical necessity to include maintenance of function. CCD also recommends clarifying coverage for high risk populations and services not addressed by guidelines. Stronger monitoring and enforcement of rules is needed.
Preventing falls in the SNF environment can be a challenge. Learn how to become a fall CSI and inspire your interdisciplinary team to meet the challenge of Falls Reduction. Improve patient care and survey outcomes.
1. Learn to detail the Benefit of Root Cause analysis.
2. Gain an understanding of the Fall Investigation process.
3. Develop a clear understanding of accurate coding in Section M.
4. Learn how to verbalize the benefit of interdisciplinary involvement and follow-up for Fall Events.
In February 2013, the Office of Inspector General (OIG) released a report entitled Skilled Nursing Facilities Often Fail to Meet Care Planning Requirements, in which they found that 26% of facilities fail to meet care planning requirements. Is your facility meeting federal guidelines for care planning? This presentation discusses the important link between the MDS 3.0, the Care Area Assessments (CAAs) and the care plan. Learn the essential components of a resident-centered care plan, how to develop a care plan that supports the clinical care that is provided to the patient, and how to proactively maintain a care plan that will meet annual survey requirements. The presentation discusses strategies for completing the CAAs more effectively, and how the CAA process can be used to create a more resident-specific care plan. Learn to develop a resident centered known as ( I careplan) through a workshop discussing different elements of the careplan, from profile, interim, and diagnosis.
1. Gain an understanding of the purpose of a Care Plan.
2. Learn to define the purpose of the discharge Care Plan and Summary.
3. Learn to to articulate the link between the MDS 3.0 assessment, the nursing Care Plan, the discharge Care Plan, and accurate RUG-IV classification.
4. Understand the the correlation between the MDS 3.0 assessment, the Care Area Assessments (CAAs), and the Care Plan.
Can your Skilled Nursing Facility (SNF) afford to provide care to Medicare patients and not receive accurate and appropriate reimbursement? The resources utilized to respond to additional documentation requests, manage denials and the loss of revenue for care provided can have a devastating impact on your facilities budget. In addition, early identification of potential issues and prompt resolution of actual issues reduces a facilities risk of hefty fines and penalties related to non-compliance.
Skilled Nursing Facilities are required to have a compliance program effective March 2013. Compliance programs strengthen and document a SNFs efforts to prevent and reduce Medicare fraud and abuse and ensure accurate and appropriate reimbursement for quality care provided. Under SNF compliance regulations Medicare has redefined the definition of fraud. When a facility has not taken all the necessary steps to ensure all the technical and clinical qualifications are supported by your medical records to prevent improper billing, fines and penalties may be applied. The critical components of an effective compliance program include monitoring and auditing to ensure Skilled Nursing Facility provider's have a formalized and proactive approach towards detecting fraud, abuse, and waste of precious company resources.
Improve participation and functional outcomes through creativity out of the gym. Functionally based treatment will ensure patients receive medically necessary physical therapy, occupational therapy and speech services. The presentation reviews practical application to Medicare requirements.
1. Learn to identify creative treatment strategies.
2. Learn to define Medicare coverage and Medicare documentation.
3. Learn to identify the clinical benefits of Functional Based Therapies.
The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. The speaker will begin this seminar by discussing the goals of Medical Review and various Medical Review programs including Recovery Audit Contractor (RAC) and Carrier (Medicare Administrative Contractor or Fiscal Intermediary) Medical Review programs.
Hospital Readmission Reduction: How Important are Follow Up Calls? (Hint: Very)SironaHealth
Starting in 2012, the Centers for Medicare and Medicaid Services (CMS) will begin withholding payments for potentially avoidable readmissions. This presentation reviews these new regulations, what causes excessive readmissions, and how hospitals can positively impact patient health by reaching out 24-72 hours after discharge.
Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. The speaker will begin this seminar by discussing recent national trends in Medical Review, reasons for increased review and the various Medical Review programs. The speaker will present specific denial trends associated with Medicare Part B Claims. The presentation will culminate in a review of the keys to responding to a medical record request and appeal tips and strategies.
Preventing falls in the SNF environment can be a challenge. Learn how to become a fall CSI and inspire your interdisciplinary team to meet the challenge of Falls Reduction. Improve patient care and survey outcomes.
1. Learn to detail the Benefit of Root Cause analysis.
2. Gain an understanding of the Fall Investigation process.
3. Develop a clear understanding of accurate coding in Section M.
4. Learn how to verbalize the benefit of interdisciplinary involvement and follow-up for Fall Events.
In February 2013, the Office of Inspector General (OIG) released a report entitled Skilled Nursing Facilities Often Fail to Meet Care Planning Requirements, in which they found that 26% of facilities fail to meet care planning requirements. Is your facility meeting federal guidelines for care planning? This presentation discusses the important link between the MDS 3.0, the Care Area Assessments (CAAs) and the care plan. Learn the essential components of a resident-centered care plan, how to develop a care plan that supports the clinical care that is provided to the patient, and how to proactively maintain a care plan that will meet annual survey requirements. The presentation discusses strategies for completing the CAAs more effectively, and how the CAA process can be used to create a more resident-specific care plan. Learn to develop a resident centered known as ( I careplan) through a workshop discussing different elements of the careplan, from profile, interim, and diagnosis.
1. Gain an understanding of the purpose of a Care Plan.
2. Learn to define the purpose of the discharge Care Plan and Summary.
3. Learn to to articulate the link between the MDS 3.0 assessment, the nursing Care Plan, the discharge Care Plan, and accurate RUG-IV classification.
4. Understand the the correlation between the MDS 3.0 assessment, the Care Area Assessments (CAAs), and the Care Plan.
Can your Skilled Nursing Facility (SNF) afford to provide care to Medicare patients and not receive accurate and appropriate reimbursement? The resources utilized to respond to additional documentation requests, manage denials and the loss of revenue for care provided can have a devastating impact on your facilities budget. In addition, early identification of potential issues and prompt resolution of actual issues reduces a facilities risk of hefty fines and penalties related to non-compliance.
Skilled Nursing Facilities are required to have a compliance program effective March 2013. Compliance programs strengthen and document a SNFs efforts to prevent and reduce Medicare fraud and abuse and ensure accurate and appropriate reimbursement for quality care provided. Under SNF compliance regulations Medicare has redefined the definition of fraud. When a facility has not taken all the necessary steps to ensure all the technical and clinical qualifications are supported by your medical records to prevent improper billing, fines and penalties may be applied. The critical components of an effective compliance program include monitoring and auditing to ensure Skilled Nursing Facility provider's have a formalized and proactive approach towards detecting fraud, abuse, and waste of precious company resources.
Improve participation and functional outcomes through creativity out of the gym. Functionally based treatment will ensure patients receive medically necessary physical therapy, occupational therapy and speech services. The presentation reviews practical application to Medicare requirements.
1. Learn to identify creative treatment strategies.
2. Learn to define Medicare coverage and Medicare documentation.
3. Learn to identify the clinical benefits of Functional Based Therapies.
The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. The speaker will begin this seminar by discussing the goals of Medical Review and various Medical Review programs including Recovery Audit Contractor (RAC) and Carrier (Medicare Administrative Contractor or Fiscal Intermediary) Medical Review programs.
Hospital Readmission Reduction: How Important are Follow Up Calls? (Hint: Very)SironaHealth
Starting in 2012, the Centers for Medicare and Medicaid Services (CMS) will begin withholding payments for potentially avoidable readmissions. This presentation reviews these new regulations, what causes excessive readmissions, and how hospitals can positively impact patient health by reaching out 24-72 hours after discharge.
Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. The speaker will begin this seminar by discussing recent national trends in Medical Review, reasons for increased review and the various Medical Review programs. The speaker will present specific denial trends associated with Medicare Part B Claims. The presentation will culminate in a review of the keys to responding to a medical record request and appeal tips and strategies.
This presentation provides a comprehensive review and forecast of the trends in Medicare Medical Review by numerous Medicare Contractors and is appropriate for all SNF Management, nursing staff, and therapy professionals. The presentation provides insight on the tidal wave of newly exposed compliance issues at the eye of the storm, leading to remote and on-site audits in the long-term care industry. Presentation highlights the historical drought in audits and the tornado effect the current scrutiny is causing amongst the SNF providers. Learn strategies to prepare records before the impending audit storm. Avoid slip ups on the seemingly invisible black ice of Medicare non-compliance. Become aware of the most recent CMS updates impacting the RAI process and subsequently reimbursement. Create an anemometer for Managers and staff to read the winds of change and create clear visibility for accurate and compliant records.
1. Learn to summarize the multiple types of Medicare Contractor Audits and associated Compliance themes.
2. Understand the trends and triggers in Compliance Audits and Common Provider Pitfalls.
3. Learn strategies for appealing Medicare Claim Denials.
Survey preparation is a never ending process and with the new QIS survey process in transition, it represents a new paradigm shift. This presentation will provide insight into key elements, tips and strategies that providers should use as part of their quality assurance survey preparation efforts. Learn from this multi-level licensed nursing home administrator with expertise in regulatory compliance sharing his lessons learned through the years.
Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of the medical review is to determine whether the services provided are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. This presentation discusses recent national trends in Medical Review, Reasons for increased review and the various Medical Review programs. The presentation highlights specific denial trends associated with claims following hospitalization for a psychiatric diagnosis. The presentation will culminate in a review of the keys to responding to a medical record request and appeal tips and strategies.
1. Learn to summarize goals of Medicare Medical Review.
2. Learn identify and articulate examples of the Medicare Medical Review Process.
3. Learn to identify strategies for interdisciplinary management of Medicare documentation requests and appeals.
Keep your MMQ and MDS Coordinators up to speed to prepare for Case Mix. Learn MDS 3.0 coding strategies and how to optimize case mix reimbursement. Learn the documentation requirements to support the RUG level achieved.
1. Learn to identify requirements for scheduling OBRA MDS Assessments for Case Mix.
2. Learn to identify Rehabilitation Case Management strategies for Clinically Appropriate placement in RUG-III and RUG-IV Classification categories.
3. Learn to identify Nursing RUG-III and RUG-IV Qualifiers.
4. Learn to identify ADL Documentation strategies.
Provisions set forth in the Affordable Care Act (ACA) require the Centers for Medicare and Medicaid Services (CMS) to broaden quality improvement activities in nursing homes. Although the mandatory implementation date for nursing homes to provide evidence of a systematic Quality Assurance and Performance Improvement (QAPI) program has been delayed, but facilities should not delay in implementing a detailed and well-documented QAPI program. This presentation moves beyond the five elements of a QAPI and begins to drill down to practical concepts for “beefing up” an existing Quality Improvement program to meet QAPI standards. Learn how to objectively assess where your facility is in the QAPI journey, and gain a deeper insight into how practical implementation of QAPI activities can be a part of the culture of excellence that is part of all successful nursing homes.
1. Learn to detail the five elements of QAPI and correlate the five elements to the twelve step action plan for QAPI implementation.
2. Learn to articulate the steps to evaluating their facilities progress in QAPI efforts.
3. Understand Performance Improvement Projects (PIPs).
4. Learn the five steps of Root Cause Analysis (RCA) and learn how to apply the RCA process to adverse events in their facility routinely.
The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. The speaker will begin this seminar by discussing the goals of Medical Review and various Medical Review programs including Recovery Audit Contractor (RAC) and Carrier (Medicare Administrative Contractor or Fiscal Intermediary) Medical Review programs.
This presentation reviews the key points of therapy and nursing documentation to support skilled care. Carrie will share tips and strategies for both responding to a medical record request and appealing a denied claim. Recommended for Administrators, Executive Directors, CEOs, CFOs, COOs and Interdisciplinary Staff.
The Skilled Nursing Facility (SNF) “Program for Evaluating Payment Patterns Electronic Report” (PEPPER) was released in April 2014 by CMS. CMS introduced this new annual report for Skilled Nursing Facilities in August 2013. PEPPER data is shared with both Medicare Administrative Contractors (MACs) and the Medicare Recovery Audit Contractors (RACs). This important report details your facility-specific Medicare claims data in certain targeted areas and compares your facility to other SNFs Nationally, by State and by Jurisdiction (Medicare Administrative Contractors/Fiscal Intermediaries).
Review the shortage of medical professionals and the increasing need for advanced practitioners to serve in primary care roles
Identify the current barriers that prevent CNP from practicing to the full extent of their education, scope and training
Outline concrete ways in which these barriers can be effectively removed so as to improve autonomy for CNP’s and quality of care for patients.
Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. As a Skilled Nursing Facility leader, are you confident in your ability to appeal any and all denied claims that may arise in your building?
https://userupload.net/yk8shpcpwk19
Dentistry can do so much these days to improve a person’s health, appearance and self-confidence. From barely noticeable braces that straighten crooked smiles to dental implants that replace missing teeth, there is a state-of-the-art solution to virtually any dental problem. Of course, like anything that involves the time and resources of skilled professionals, highly technical and sophisticated dental treatment doesn’t come inexpensively; indeed, the phrase “you get what you pay for” probably applies doubly to dentistry. Also, the types of treatment mentioned above, as well as many others, are often considered elective and therefore may not be covered (or only partially covered) by dental insurance. This can be the case even when a given procedure offers proven health benefits.
This presentation discusses the key elements of a Corporate Compliance program allowing an organization to self-monitor operations on an ongoing basis to ensure compliance with supportive documentation to adhere to applicable laws and the organization’s own policies and procedures.
Appropriate for CEOs, CFOs, Administrators, Nursing Management, Direct Care Nurses in a SNF, MDS Coordinators and Business Office Managers.
A comprehensive review of the Medicare appeal process. Appropriate for all SNF nursing staff, management, and therapy professionals. The presentation discusses the level of Medicare appeal, how facilities can thoroughly and timely manage the appeal process, and how facilities can participate in a successful ALJ hearing.
Compliance and Legal Risks in Laborist, Surgicalist, and Hospitalist Arrangem...MD Ranger, Inc.
Have you structured your hospital-based physician contracts to address all aspects of compliance?
Hospitalist agreements involve unique compliance and financial issues, particularly when global payments and advanced practice providers are involved. Risks include indirect compensation, billing and other compliance issues. This presentation will discuss compliance risks and provide guidance on how to structure compliant contracts and business arrangements.
The Affordable Care Act (ACA) requires non-grandfathered health plans to cover certain preventive health services without imposing cost-sharing requirements for the services. This preventive care coverage requirement, which generally took effect for plan years beginning on or after Sept. 23, 2010, does not apply to grandfathered health plans.
This presentation provides a comprehensive review and forecast of the trends in Medicare Medical Review by numerous Medicare Contractors and is appropriate for all SNF Management, nursing staff, and therapy professionals. The presentation provides insight on the tidal wave of newly exposed compliance issues at the eye of the storm, leading to remote and on-site audits in the long-term care industry. Presentation highlights the historical drought in audits and the tornado effect the current scrutiny is causing amongst the SNF providers. Learn strategies to prepare records before the impending audit storm. Avoid slip ups on the seemingly invisible black ice of Medicare non-compliance. Become aware of the most recent CMS updates impacting the RAI process and subsequently reimbursement. Create an anemometer for Managers and staff to read the winds of change and create clear visibility for accurate and compliant records.
1. Learn to summarize the multiple types of Medicare Contractor Audits and associated Compliance themes.
2. Understand the trends and triggers in Compliance Audits and Common Provider Pitfalls.
3. Learn strategies for appealing Medicare Claim Denials.
Survey preparation is a never ending process and with the new QIS survey process in transition, it represents a new paradigm shift. This presentation will provide insight into key elements, tips and strategies that providers should use as part of their quality assurance survey preparation efforts. Learn from this multi-level licensed nursing home administrator with expertise in regulatory compliance sharing his lessons learned through the years.
Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of the medical review is to determine whether the services provided are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. This presentation discusses recent national trends in Medical Review, Reasons for increased review and the various Medical Review programs. The presentation highlights specific denial trends associated with claims following hospitalization for a psychiatric diagnosis. The presentation will culminate in a review of the keys to responding to a medical record request and appeal tips and strategies.
1. Learn to summarize goals of Medicare Medical Review.
2. Learn identify and articulate examples of the Medicare Medical Review Process.
3. Learn to identify strategies for interdisciplinary management of Medicare documentation requests and appeals.
Keep your MMQ and MDS Coordinators up to speed to prepare for Case Mix. Learn MDS 3.0 coding strategies and how to optimize case mix reimbursement. Learn the documentation requirements to support the RUG level achieved.
1. Learn to identify requirements for scheduling OBRA MDS Assessments for Case Mix.
2. Learn to identify Rehabilitation Case Management strategies for Clinically Appropriate placement in RUG-III and RUG-IV Classification categories.
3. Learn to identify Nursing RUG-III and RUG-IV Qualifiers.
4. Learn to identify ADL Documentation strategies.
Provisions set forth in the Affordable Care Act (ACA) require the Centers for Medicare and Medicaid Services (CMS) to broaden quality improvement activities in nursing homes. Although the mandatory implementation date for nursing homes to provide evidence of a systematic Quality Assurance and Performance Improvement (QAPI) program has been delayed, but facilities should not delay in implementing a detailed and well-documented QAPI program. This presentation moves beyond the five elements of a QAPI and begins to drill down to practical concepts for “beefing up” an existing Quality Improvement program to meet QAPI standards. Learn how to objectively assess where your facility is in the QAPI journey, and gain a deeper insight into how practical implementation of QAPI activities can be a part of the culture of excellence that is part of all successful nursing homes.
1. Learn to detail the five elements of QAPI and correlate the five elements to the twelve step action plan for QAPI implementation.
2. Learn to articulate the steps to evaluating their facilities progress in QAPI efforts.
3. Understand Performance Improvement Projects (PIPs).
4. Learn the five steps of Root Cause Analysis (RCA) and learn how to apply the RCA process to adverse events in their facility routinely.
The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. The speaker will begin this seminar by discussing the goals of Medical Review and various Medical Review programs including Recovery Audit Contractor (RAC) and Carrier (Medicare Administrative Contractor or Fiscal Intermediary) Medical Review programs.
This presentation reviews the key points of therapy and nursing documentation to support skilled care. Carrie will share tips and strategies for both responding to a medical record request and appealing a denied claim. Recommended for Administrators, Executive Directors, CEOs, CFOs, COOs and Interdisciplinary Staff.
The Skilled Nursing Facility (SNF) “Program for Evaluating Payment Patterns Electronic Report” (PEPPER) was released in April 2014 by CMS. CMS introduced this new annual report for Skilled Nursing Facilities in August 2013. PEPPER data is shared with both Medicare Administrative Contractors (MACs) and the Medicare Recovery Audit Contractors (RACs). This important report details your facility-specific Medicare claims data in certain targeted areas and compares your facility to other SNFs Nationally, by State and by Jurisdiction (Medicare Administrative Contractors/Fiscal Intermediaries).
Review the shortage of medical professionals and the increasing need for advanced practitioners to serve in primary care roles
Identify the current barriers that prevent CNP from practicing to the full extent of their education, scope and training
Outline concrete ways in which these barriers can be effectively removed so as to improve autonomy for CNP’s and quality of care for patients.
Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. As a Skilled Nursing Facility leader, are you confident in your ability to appeal any and all denied claims that may arise in your building?
https://userupload.net/yk8shpcpwk19
Dentistry can do so much these days to improve a person’s health, appearance and self-confidence. From barely noticeable braces that straighten crooked smiles to dental implants that replace missing teeth, there is a state-of-the-art solution to virtually any dental problem. Of course, like anything that involves the time and resources of skilled professionals, highly technical and sophisticated dental treatment doesn’t come inexpensively; indeed, the phrase “you get what you pay for” probably applies doubly to dentistry. Also, the types of treatment mentioned above, as well as many others, are often considered elective and therefore may not be covered (or only partially covered) by dental insurance. This can be the case even when a given procedure offers proven health benefits.
This presentation discusses the key elements of a Corporate Compliance program allowing an organization to self-monitor operations on an ongoing basis to ensure compliance with supportive documentation to adhere to applicable laws and the organization’s own policies and procedures.
Appropriate for CEOs, CFOs, Administrators, Nursing Management, Direct Care Nurses in a SNF, MDS Coordinators and Business Office Managers.
A comprehensive review of the Medicare appeal process. Appropriate for all SNF nursing staff, management, and therapy professionals. The presentation discusses the level of Medicare appeal, how facilities can thoroughly and timely manage the appeal process, and how facilities can participate in a successful ALJ hearing.
Compliance and Legal Risks in Laborist, Surgicalist, and Hospitalist Arrangem...MD Ranger, Inc.
Have you structured your hospital-based physician contracts to address all aspects of compliance?
Hospitalist agreements involve unique compliance and financial issues, particularly when global payments and advanced practice providers are involved. Risks include indirect compensation, billing and other compliance issues. This presentation will discuss compliance risks and provide guidance on how to structure compliant contracts and business arrangements.
The Affordable Care Act (ACA) requires non-grandfathered health plans to cover certain preventive health services without imposing cost-sharing requirements for the services. This preventive care coverage requirement, which generally took effect for plan years beginning on or after Sept. 23, 2010, does not apply to grandfathered health plans.
How to convince key decisionmakers to integrate health literacyChristopher Trudeau
Looking to make the business & regulatory case for integrating health literacy or patient-centered care into your hospital or health system. This presentation gives practical tips and example slides I've used to help make the case.
Global Medical Cures™ | Community Strategies for Preventing CHRONIC DISEASESGlobal Medical Cures™
Global Medical Cures™ | Community Strategies for Preventing CHRONIC DISEASES
DISCLAIMER-
Global Medical Cures™ does not offer any medical advice, diagnosis, treatment or recommendations. Only your healthcare provider/physician can offer you information and recommendations for you to decide about your healthcare choices.
DQ 3-2Integrated health care delivery systems (IDS) was develope.docxelinoraudley582231
DQ 3-2
Integrated health care delivery systems (IDS) was developed to initiate excellence health care access and quality of care to entire populations and community by collaborating and coordinating diverse healthcare professionals. Main driving force of IDS is patient centered care by using resources such as collaborating care from physicians and allied health care professionals to construct continuum of care, to deliver care in the most cost-effective way, utilize trained and competent providers by utilizing evidenced -based practice and combine innovation such as EHR (Electronic Health Records) system and team work to produce improved healthcare system.
Excellence in care is attainable by incorporating allied healthcare professional, as high quality care is possible when coordination is unified and covers all areas of responsibilities. For an example-combining resources and coordination of care by involving physicians, dietitian, physical therapy or occupational therapy to work with patient diagnosed with obesity by promoting teamwork approach and ultimately delivering endurance in care and utilizing various resources.
Barriers to IDS can be a huge block in delivering quality care. Among many one limitation is physicians not participating in integrated healthcare system, which disconnect physicians from team based approached by deterring continuous quality improvement (essentialhospitals.org, n.d). This is because, system such as EHR or new innovative quality assurance programs are time consuming and overwhelming, thus decline in physicians support in IDS programs. By implementing user friendly system approach, enforcing focused based care and accepting the necessity of evidenced based practice can improve these barriers. Hence, increasing clinical expertise to produce better service and quality of care in integrated delivery system.
Essentialhospitls.org (n.d). Retrieved from: http://essentialhospitals.org/wp-content/uploads/2013/12/Integrated-Health-Care-Literature-Review-Webpost-8-22-13-CB.pdf
Dq 3-1
1.
In the US, there is not one type of health care system but rather a subset of systems, some of them catering to specific populations. These subsystems include managed care, military, and vulnerable populations. Managed care is a health care delivery system that seeks to achieve efficiency by integrating the basic functions of health care delivery, employs mechanisms to control utilization of medical services, and determines the price at which the services are purchased and how much the providers get paid, military health care system is available free of charge to active duty military personnel and covers preventative and treatment services that are provided by salaried health care personnel and this system combines public health with medical services, and vulnerable population subsystem offers comprehensive medical and enabling services targeted to the needs of vulnerable populations and government health insurance programs provide.
The Heartaches Associated with Billing for Cardiac DevicesPYA, P.C.
PYA Principal Denise Hall-Gaulin and Consulting Manager Joanna Malcolm presented a free webinar for the Georgia chapter of the Healthcare Financial Management Association, on Tuesday, December 6, 2016.
The presentation was geared toward C-suite hospital leaders, compliance officers, in-house counsel, operational leaders, and patient accounting leadership, and covered:
The criteria for implantable cardioverter defibrillators (ICDs), pacemakers, and other devices
The documentation requirements for payment
The prerequisites for a clean audit
Chapter 18 Private and Government Healthcare Systems PriMorganLudwig40
Chapter 18
Private and Government Healthcare Systems
Private and Government Healthcare Systems
In the United States, health insurance coverage is generally classified as either private (non-government) coverage or government-sponsored coverage.
Healthcare Coverage vs. Uninsured
The National Center for Health Statistics defines health insurance as public and private payers who cover medical expenditures incurred by a defined population in a variety of settings.
In the United States, the risk of becoming uninsured increases significantly for those earning low wages, the unemployed, and when employers are unable to provide insurance to workers.
Table 5-2 presents the trend of declining health insurance coverage.
Private Health Insurance
The concept of insurance is to combine the healthcare experiences of many enrollees in order to reduce expenses for any one individual to a manageable prepayment amount.
Employment-Based Plans is coverage offered through one’s own employment or a relative’s employment.
It may be offered by an employer or by a union.
Private Health Insurance Continued
Direct-Purchase/Fee-For-Service Plans are the traditional type of healthcare policy.
The physician sets a price for each type of service delivered, and then the client or insurance company pays the fee.
This type of health insurance provides the most choices of doctors and hospitals.
Private Health Insurance Continued
The two kinds of fee-for-service coverage are basic and major medical.
Basic covers some hospital services and supplies, such as X-rays and prescribed medicine.
Major medical insurance covers the cost of long-term, high-cost illnesses or injuries plus whatever basic did not cover.
Private Health Insurance Continued
Group Contract Insurance—to make hospitals and physicians products and services affordable to ordinary people in the United States.
With unmanaged care (fee-for-service) payments, healthcare providers could increase the number of single services they deliver in order to increase profit.
Private Health Insurance Continued
Managed Care—manages the cost and delivery of healthcare services, the quality of that healthcare, and access to care.
Managed care influences how much healthcare clients can use.
Health Maintenance Organizations (HMOs) are prepaid health plans.
The goal of an HMO is to provide affordable, well-organized healthcare by allowing clients to prepay (capitation payment) on a regular monthly basis for all services provided.
Private Health Insurance Continued
Including physicians’ visits, hospital stays emergency care, surgery, laboratory (lab) tests, X-rays, and therapy for all members and their families.
There may be a small co-payment for each office visit, such as $15 for a doctor’s visit or $50 for hospital emergency room treatment.
Private Health Insurance Continued
Point-of-Service Plans (POS) offer enrollees the option of receiving services from participating or nonparticipating prov ...
Patient Resource: Medicare Observation Versus Admit DaysTerri Embry RN BS
This resource provides information a patient, their advocate or a health care professional can use to learn about this topic. Hyperlinks are embedded to allow for self guided research and is encouraged.
4 hours ago
Amy Miller
RE: Discussion - Week 7
Collapse
NURS 6050C: Policy and Advocacy for Improving Population Health
Main Question Post. The Patient Protection and Affordable Care Act of 2010 created several positive healthcare policies such as affordable health care, lifting the preexisting health condition clause from health insurance, requiring facilities to make healthcare charges public knowledge, and enforcing healthcare providers to become active in improving quality and health outcomes for patients (Library of Congress, n.d.). The act addressed a combination of the health care drivers of cost, quality, and access. According to a report released by the White House Press Secretary on April 17, 2014, “The Affordable Care Act is working. It is giving millions of middle class Americans the health care security they deserve, it is slowing the growth of health care costs and it has brought transparency and competition to the Health Insurance Marketplace.” (The White House, 2014). However, the price some healthcare providers had to pay a heavy financial - forcing some providers out of business. The negative side of the act is seldom portrayed in the news and media.
Section 3131(a) of the act required payment for home health services to be rebased over a period of four years (Centers for Medicare & Medicaid Services, 2013); resultant in a 2.8% reduction beginning in 2014 for four consecutive years totaling a reduction in payment of 11.6%. The reductions were placed along with mandates for quality reporting, new forms, and new processes resulting in increased administrative overhead costs while shouldering the burden of financial reductions.
Initiating a Change in Policy Process
Living in a rural community, I witness firsthand the lack of access to care as there are limited numbers of primary care providers. Couple the limited access to providers with the amount of paperwork and forms that must be signed by a physician and patients are not referred to home health services as often as one should be – the result is the patient presenting to the emergency room or a hospitalization to have one’s health care needs met. Currently, Medicare and Medicaid do not allow physician assistants or advanced practice registered nurses (APRNs) to sign the necessary orders and plan of care for home health services – only a “doctor of medicine, osteopathy, or podiatric medicine” may sign for services (Government Publishing Office, 2014, p. 693). I would like to use the knowledge gained as an APRN to legislate for this mandate to be changed and allow both physician assistants and APRNs to sign for coverage of home health services.
The Kingdon Model would be utilized for the legislation process by finding the three streams of problem, policy, and politics to coordinate with the above-mentioned issue (Milstead, 2019, p. 24). The problem would consist of the burdensome amount of paperwork imposed upon.
4Seeking an Effective Care ContinuumLearning Objective.docxblondellchancy
4
Seeking an Effective Care Continuum
Learning Objectives
After reading this chapter, you should be able to:
• Identify programs that address the health issues surrounding workplace accidents.
• Assess the need for a continuum of care that comprises a comprehensive approach to
health care for vulnerable populations.
• Identify the preventive care services available to vulnerable populations.
• Examine the treatment services available to vulnerable populations.
• Explain the options that vulnerable populations have for accessing long-term care.
Courtesy of Kurhan/Fotolia
bur25613_04_c04_111-148.indd 111 11/26/12 10:30 AM
CHAPTER 4
Critical Thinking
OSHA provides many programs to ensure workers’ health and safety. Is there a similar program for
health care elsewhere? If not, could OSHA be used as a model to create or redesign existing programs?
Introduction
Introduction
Workplace injuries, deaths, and work-related illnesses cost the United States approximately $693.5 billion a year (National Safety Council, 2009). The Occu-pational Safety and Health Administration (OSHA), established in 1970,
ensures safe and healthy working conditions for men and women by setting standards
and providing training, outreach, and education. In other words, OSHA focuses on the
prevention of injuries by regulating the workplace.
In contrast, workers’ compensation programs, which are administered through the
Department of Labor, help workers who have already sustained a work-related injury or
an occupational disease. These programs focus on wage replacement, medical treatment,
and rehabilitation services coverage. Employers pay into the workers’ compensation
programs through companies that work to mitigate costs to insurance companies, called
insurance underwriters, or government programs to help cover these expenses. Although
paying into the national workers’ compensation program represents a significant expense
for employers, lost employee productivity is more costly. To minimize workers’ compen-
sation and lost productivity expenses, many employers have preventive workplace safety
programs that include educational sessions on safety and even posters with images and
safety messages to remind workers of best practices for safety. These preventive programs
aim to minimize risks both to the workers and the employers. Some of these programs
are available through OSHA, the national programs for workers’ compensation, or their
company insurance or liability underwriter.
Workplace safety programs and workers’ compensation programs provide a continuum
to address the health issues surrounding workplace accidents. From prevention to treat-
ment to rehabilitation to return-to-work, workplace safety and workers’ compensation
programs address the specific health care needs of America’s working population. This is
one example of the way a continuum of care works and how programs can work together
to create a continuum of care. E ...
Read the scenario that you will use for the Individual Projects in ea.pdfashokarians
Read the scenario that you will use for the Individual Projects in each week of the course. The
Centers for Medicare and Medicaid Services (CMS) has taken on a more visible role in health
care delivery. Many changes have transpired to improve patient safety along with the
implementation of additional quality metrics, and these changes impact reimbursement rates
Likewise, the Patient Protection and Affordable Care Act has changed the reimbursement fee
structure of Medicare and Medicaid reimbursement for health care services. Other legislation
including the HITECH Act and the Medicare Authorization and CHIP Reactivation Act of 2015
(MACRA) all impact how healthcare organizations receive reimbursement and demonstrate use
of data to improve quality and delivery of patient care Mr. Magone, CEO of Healing Hands
Hospital, has asked you to join the \"Future of Healing Hands Task Force, and your first
assignment is to work with the Hospital Chief Financial Officer, Mr. Johnson, and provide a
summary of the current regulations regarding Medicare reimbursement including how MACR
impact reimbursement if/when Healing Hands coordinates delivery of services by affiliating with
physician practices For this assignment, write a 2-3 page report that you will deliver to Mr.
Magone on how the new CMS initiatives and regulations impact the organization\'s revenue
structure. In your presentation, address the following questions: Why did CMS become more
involved in the reimbursement component of health care? How does CMS\'s involvement impact
the reimbursement model for Healing Hands Hospital and other health care organizations If
CMS reimbursement regulations for Medicare and Medicaid change, does it follow that other
insurance providers change heir policies on reimbursement? What tools can be implemented to
ensure organizations such as Healing Hands Hospital and physician practices are meeting the
policies and procedures set forth by CMS? Identify 3 tools from the CMS Web site that are
helpful in meeting the requirements for Medicare reimbursement set forth by CMS
Solution
Part-a & part-b:
The physician’s work, practice expense, and malpractice, RVU values, CMS (centers for
Medicare and Medicaid services) is required to control overall expenditures in health care
organization. Therefore, CMS become highly involved in the reimbursement component of
health care to patients as per their \"insurance packages\". The CMS\' involvement in “budget
Neutrality” & the reimbursement model at Healing Hand hospital & other health care
organizations is mainly for physician RVU based payments from Medicare & Medicare that can
control its physician costs by adjusting physician payment rates based on “previous periods in a
calendar year” as per federal acts and regulations. The Medicare is going to control physicians
costs according to “medical procedures and medical visits of their record” in a Jan- 1 ending Dec
31. Conversion Factor is main basis to control the physician costs ac.
Topics covered in this 10-26-2007 presentation to the TWG include background and brief updates of System
Transformation Initiative projects; a benefits package update, and a housing action plan update.
Study Guide Health Care ReformHealth Care Reform OverviewWhe.docxpicklesvalery
Study Guide: Health Care Reform
Health Care Reform: Overview
When it comes to healthcare in America, we seem to believe that more is better--but does more healthcare result in better health? As a nation, we spend more on healthcare per person than any European country, yet our health outcomes are worse. The PBS documentary, Money and Medicine was aired in 2012, and addresses one of the key issues of healthcare reform--the cost of health care. Watch the trailer below, or the entire episode here: http://video.pbs.org/video/2283573727/
(Links to an external site.)
http://youtu.be/a9oEtRwoVxs
(Links to an external site.)
The Affordable Care Act
The Patient Protection and Affordable Care Act (ACA), passed in 2010, is a collection of laws that were created to reform health insurance and healthcare.
The ACA significantly impacts nurses both personally and professionally. Bedside nurses are impacted by organizational changes that affect patient care, and may be providing information and resources to patients and caregivers about the ACA. However, as Hynds, Hatch and Samuels (2014) noted, nurses indicate they need more knowledge to understand the ACA policy implications of their practice.
Now, you can either read the 974 pages of the law itself, or you can watch this short, animated video produced by the Kaiser Family Foundation, and visit the helpful online resources below:
http://youtu.be/JZkk6ueZt-U
(Links to an external site.)
The YouToons Get Ready for Obamacare
0:01 / 6:52
<div class="player-unavailable"><h1 class="message">An error occurred.</h1><div class="submessage"><a href="http://www.youtube.com/watch?v=JZkk6ueZt-U" target="_blank">Try watching this video on www.youtube.com</a>, or enable JavaScript if it is disabled in your browser.</div></div> Minimize Video
Affordable Care Act: Five Years Later
The Commonwealth Fund has developed several online, interactive resources to illustrate the impact of the Affordable Care Act in its first five years of implementation. Through personal stories, population and health systems data analysis, and graphics, the Commonwealth fund paints the picture of the impact of the ACA on individuals, businesses, providers and healthcare systems. Take some time to explore these resources in preparation for this week's discussion board. Link: The Affordable Care Act: A Look Back at the First Five Years.
(Links to an external site.)
Review the two interactive digital features: Coverage Reform
(Links to an external site.)
and Delivery Reform
(Links to an external site.)
.
Value-Based Purchasing--"Pay for Performance"
Increasingly, hospitals and healthcare providers are reimbursed not just for the amount of services provided (fee-for service), but for the results that are achieved for a particular patient population. As nurses, you may have observed policy changes that emphasize patient experience, prevention of hospital-acquired infections, and effective discharge planning ...
Similar to Ccd prevention regulation comments draft (20)
1. September 17, 2010
Office of Consumer Information and Insurance Oversight
Department of Health and Human Services
Attention: OCIIO-9992-IFC
PO Box 8016
Baltimore, MD 21244
Office of Health Plan Standards and Compliance Assistance
Employee Benefits Security Administration, Room N-5653
U.S. Department of Labor
200 Constitution Avenue NW
Washington, DC 20210
Attention: RIN 1210-AB44
Internal Revenue Service
CC: PA: LPD: PR, (REG-120391-10)
Room 5025
P.O. Box 7604 Ben Franklin Station
Washington, DC 20044
Attention: REG 120391-10
RE: CCD Comments on Interim Final Rules for Group Health Plans and Health
Insurance Issuers Relating to Coverage of Preventive Services Under the Patient
Protection and Affordable Care Act (File Code OCIIO-9992-IFC/RIN 1210-
AB44/REG–120391-10)
Dear Sir or Madam:
The co-chairs of the Consortium for Citizens with Disabilities (CCD) Health Taskforce
appreciate the opportunity to comment on the interim final rules that implement
provisions of the Patient Protection and Affordable Care Act (P.L.111-148) regarding
coverage of preventive services. CCD strongly supports coverage of preventive services
with no cost sharing for beneficiaries and believes that the elimination of cost sharing for
preventative services demonstrates a commitment to reducing injury, illness, disability
and secondary disability for the American public and promoting healthy quality of life. In
addition, an increased emphasis on prevention changes the focus of health care from
exclusively treating conditions to a focus on health promotion that will reduce health care
costs and improve quality of life.
1660 L Street, NW, Suite 701 • Washington, DC 20036 • PH 202/783-2229 • FAX 785-8250 • Info@c-c-d.org • www.c-c-d.org
2. We provide the following comments so that the Departments can strengthen the interim
final rules.
CCD is a coalition of approximately 100 national disability organizations working
together to advocate for national public policy that ensures the self determination,
independence, empowerment, integration and inclusion of children and adults with
disabilities in all aspects of society. Since 1973, the CCD has advocated on behalf of
people of all ages with physical and mental disabilities and their families. CCD has
worked to achieve federal legislation and regulations that assure that the 54 million
children and adults with disabilities are fully integrated into the mainstream of society.
Definition and Scope of Preventive Services
According to statute, plans must provide coverage for all of the following items and
services and plans may not impose any cost-sharing requirements (co-payment, co-
insurance, or deductibles) to those services.
• Evidence-based items or services that have in effect a rating of A or B in the
current recommendations of the United States Preventive Services Task Force
http://www.uspreventiveservicestaskforce.org/.
• Immunizations for routine use in children, adolescents, and adults that have in
effect a recommendation of the Centers for Disease (CDC) Control Advisory
Committee on Immunization Practices
http://www.cdc.gov/vaccines/recs/acip/default.htm
• Evidence informed preventive care and screenings for infants, children, and
adolescents which are provided for in comprehensive guidelines supported by
the Health Resources and Services Administration (HRSA)
http://mchb.hrsa.gov/programs/training/brightfutures.htm. These “Bright
Futures” guidelines were developed in collaboration with the American
Academy of Pediatrics (AAP) and detailed information is available at
http://brightfutures.aap.org/.
• Evidence informed preventive care and screenings for women supported by
HRSA http://mchb.hrsa.gov/whusa09/hsu/pages/305pc.html.
While CCD supports the requirement to provide these services at no cost and welcomes
the resulting expanded access to preventive services, we are concerned about too severely
limiting preventive services that will be covered with no cost sharing to those that have
been evaluated and rated by U.S. Preventive Services Task Force (USPSTF), the Centers
for Disease (CDC) Control Advisory Committee on Immunization Practices, and the
Health Resources and Services Administration (HRSA). In order to be more effective
there must be a lifestyle and function component to preventive services that will allow
individuals with and without disabilities and chronic conditions to access services that
maintain independent, productive, healthy lives.
Disability advocates have long proposed a broad definition of “medical necessity” – one
that recognizes the value of maintenance of function and not only improvement. If this
prevention initiative is to be effective in the long run in helping people with disabilities
and chronic conditions a broader recognition and definition of preventive services and
medical necessity to encompass maintenance of function and prevention of secondary
disabilities is critical. The following definition of medical necessity should be applied to
the preventive services initiative.
3. The CCD believes that a federal definition of medical necessity should require
plans to cover services that are: calculated to prevent, diagnose, correct, or
ameliorate a physical or mental condition that threatens life, causes pain or
suffering, or results in illness, disability, or infirmity; calculated to maintain or
preclude deterioration of health or functional ability; individualized, specific, and
consistent with symptoms or confirmed diagnosis of the illness, disability, or
injury under treatment; not in excess of the individual's needs; necessary and
consistent with generally accepted professional medical standards as determined
by the Secretary of Health and Human Services or the state Department of
Health; and reflective of the level of service that can be safely provided and for
which no equally effective treatment is available.
Frequency of Recommended Screenings:
Where the guidelines are silent as to frequency, the interim rules allow health plans to set
limits based on “reasonable medical management techniques” - a term that is not defined
in the reg. CCD is concerned with leaving the definition of this phrase to health plans to
exercise such discretion. CCD recommends:
• Definition: The regulations should clearly define “reasonable medical
management techniques.”
• Source of evidence: plans should use and publicly identify a credible
reference/source in making such determinations; (such as but not limited
to the Millman Care Guidelines: www.careguidelines.com )
• Recourse: Enrollees must be provided right to appeal these determinations
– both to their health plans and to the appropriate oversight agency to and
ensure adequate enforcement.
High Risk Populations Including Individuals with Disabilities and Chronic
Conditions
While some USPSTF recommendations address screenings for high risk populations,
others do not. In the case where the USPSTF recommendation is silent as to high-risk
populations and a health care provider recommends more frequent screenings than the
USPSTF for a high risk patient, the health care provider recommendation should guide
the health plan in such circumstances and the individual should be eligible for additional
no-cost screenings. When a physician has recommended the increased screening due to
higher risk, that patient should receive those screenings with no additional cost sharing.
For patients with certain chronic conditions, screenings are used as a form of disease
monitoring, but for others with chronic conditions who are at higher risk for certain
preventable conditions, screenings are a crucial prevention tool and essential to reducing
secondary disability. The final regulations should clarify and distinguish the two types of
screenings for patients with chronic conditions: ensuring that additional screenings to
prevent secondary disability are covered at no cost when recommended by a physician,
consistent with our recommendation for high risk populations as provided above.
Clarification is Needed Regarding Services Not Recommended by USPSTF and
Those Not Yet Evaluated by USPSFT
The statute provides, and the regulations reflect, that plans are allowed to deny coverage
for services that are “not recommended” by the Task Force – but this is not defined. We
are concerned that this would inadvertently give plans express permission to deny
coverage altogether for screenings that are simply not addressed by the USPSTF. The
4. final regulations should be clarified to state that “not recommended” by the USPSTF
means those services receiving a “grade D” from the Task Force. Services receiving a
grade D, by definition, means “The USPSTF recommends against the service.”
The USPSTF is expected to present recommendations on falls prevention and other
activities in the near future. CCD recommends that the final regulations clearly state a
timeline for requiring health plans to incorporate recommended services as they are
identified by the USPSTF.
Value Based Insurance Design (VBID)
According to statutory intent regulations defining VBID should make it clear that the
program must be aimed at improving health outcomes and increasing quality of care.
Preventive services should be fully available in these plans. A program that aims to
reduce costs by limiting services or access is not a value-based program.
Notice to Beneficiaries
Coverage of preventive services is an important new protection for many insurance plan
enrollees. Accordingly, clear notice should be provided to plan enrollees about no-cost
sharing for recommended preventive screenings and services. Specific notice should be
provided regarding preventive services available to high risk populations including
individuals with disabilities and chronic conditions. To ensure standardization, HHS and
DOL should provide a form for plans to use.
Monitoring and Enforcement
The success of the prevention initiative relies heavily upon the effectiveness of
monitoring and enforcement of these rules. Final regulations must clearly address
monitoring and enforcement including specific appeal rights, and remedies. Furthermore,
the regulations should provide for the Departments (HHS and DOL) to exercise oversight
over plan compliance with these regulations complete with enforcement capability.
Conclusion
CCD believes the interim final rules are a significant step forward for persons with
disabilities and chronic conditions. Nonetheless, we believe that the rules could be further
strengthened in significant ways. If you have any questions, please feel free to contact
any of the Health Task Force Co-Chairs listed below. Thank you for your consideration
of our comments.
Sincerely:
CCD Health Task Force Co-Chairs:
Mary Andrus- Easter Seals mandrus@easterseals.com
Angelo Ostrom- Epilepsy Foundation aostrom@efa.org
Peter Thomas- Brain Injury Association peter.thomas@ppsv.com
Tim Nanof- American Occupational Therapy Association tnanof@aota.org
Julie Ward- The Arc of the US & United Cerebral Palsy of America ward@thedpc.org