Business and Management

Part 1,

The mere fact the Medicare billing guidelines have over three hundred pages, it is indication of the complexity of the process overall. After reviewing the guidelines and the level of detail to which they have actually been written, I am of the opinion they do not serve a good purpose. While it is understood there needs to be guidelines that will regulate reimbursement rates based on services delivered and their geographic areas, the paper billing process is complex, cumbersome and gives opportunity to the fraudulent activity that has been seen for many years.

A review of the claims processed by Medicare from 2001 to 2010 yield the following key findings: 1) healthcare professionals have steadily billed Medicare higher rates resulting in $11 billion dollars of inflated charges, 2) up-coding or charging for more complex services than those delivered, 3) much of the increase of higher billing practices seems to happen in hospital emergency rooms, and 4) an increase in the abuse of billing for costly services seems to be on the rise due to lax oversight and the transitioning to electronic records which can actually contribute to the billing abuse (Schulte and Donald, 2012). With the reimbursement rates from Medicare for physician services not keeping pace with the rising costs of inflation which physician offices are faced with, it has left them no alternative but to find creative ways to make ends meet. While CMS feels most physicians and hospitals are honest in their billing practices, it has left room for the occasional overbilling which is costing taxpayers millions of dollars on a yearly basis. It is understandable that costs for medical services will vary based on geographic area, however in order for the system to work it is also necessary for the system to take into account the economic factors, such as inflation that impact the healthcare providers when establishing the reimbursement rates.

Part 2

I do not believe Medicare billing guidelines are served well. Medicare is the federal health insurance program for the elderly and disabled. There are two major Medicare programs-Part A and Part B. Part A covers some areas such as hospitalization, hospice, skilled nursing facilities, and some home health services. Part B covers some areas such as physician services, outpatient hospital services, laboratory charges, medical equipment, and other home health services. The federal government spent a lot on Medicare services in the past years. According to the data from Social Security Administration, the budget on Medicare services increased from $57.9 billion to $271 billion in 2003 (Levinson, 2013). In order to reduce costs and prevent fraud, the government created a complex regulatory structure for Medicare billing and reimbursement. The Medicare billing guidelines are complex and vague in some areas, such as elective surgeries, initial services, and collaboration. In terms of initial services, the advanced practice registered nurse (APRN) may or may not be able to charge independently for a patient with a chronic medical condition but a new complaint, say a diabetic patient who now has difficulty breathing, depending on whether “initial service” reflects the initial visit for diabetes management or the initial visit for the new complaint of dyspnea. The governments should clarify the standard for initial service.

Medicare Part A provides inpatient hospital insurance benefits and coverage of extended care services for beneficiaries after they are discharged from hospitals. Medicare requires that certain elective surgeries be performed in an inpatient hospital setting. According to research by Dainel Levinson, in the calendar years 2009 and 2010, Medicare made Part A prospective payments to hospitals of $597 million for inpatient claims that involved a canceled elective surgery. Almost $55 million involved short-stay (2 days or fewer) claims (Levinson, 2013). When an inpatient hospital admission is based on the expectation that a patient will have elective surgery but that surgery does not occur, that cancellation would generally make the admission not reasonable and necessary. The government should revise the admission policy for elective surgeries to reduce claims for patients who did not have surgery in a hospital.

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