Discussion: Participation in Government-Sponsored Plans
Description
Respond to at least two colleagues who chose different government-sponsored plans. In your response, make sure to contribute additional information (e.g., real-life story, current event, additional research) to further enrich your education and the Discussion. Be sure to support your responses with the Learning Resources.
https://www.cms.gov/Medicare/Billing/ElectronicBil…
https://www.cms.gov/About-CMS/Agency-Information/H…
https://oig.hhs.gov/oas/reports/region1/11100532.p…
Post #1
RE: Discussion – Week 2
COLLAPSE
Indian Health Services is a government-sponsored plan that provides healthcare to American Indians and Alaska Natives. It is governed by the Department of Health and Human Services, and works to protect and honor the culture and rights of the Indian tribes. (Harrington, 2016). This agency is given a set amount of funding each year to provide healthcare for its specific population. (Friedman, 2016). Indian Health Services provides numerous hospitals, health centers, and health stations with a considerable amount of staff available to serve patients. (Harrington, 2016). While those covered under IHS are able to receive the same services as those with other government insurance, care is not as easily accessible. There are certain facilities that accept this coverage, but are not conveniently located. (Friedman, 2016). If there is a facility that will see a patient with IHS, whether or not that coverage is accepted, there is the risk of receiving less quality care. In addition, Indian and Alaska Native patients are not able to take advantage of their full benefits if not seen at an IHS facility. (Friedman, 2016). Despite these shortcomings, the government continues to work toward its mission of raising the health of our American Indian and Alaska Native population.
In order to receive Indian Health Services benefits, one must meet certain criteria. The individual must be an American Indian and/or Alaska Native, which can be proven by membership in a federally-recognized tribe, participation in tribal affairs, or residence on tax exempt land or restricted property. (U.S. Department of Health and Human Services, n.d.). Individuals that are not Indian are able to receive care, and fall under the categories of children, spouses, and pregnant non-Indian women. (U.S. Department of Health and Human Services, n.d.). If a person is under the age of 19 years old, is the child of an eligible Indian, and does not qualify for any other coverage, he or she can receive services under IHS. (U.S. Department of Health and Human Services, n.d.). Spouses of eligible Indians who are unable to receive other insurance are qualify for this program. (U.S. Department of Health and Human Services, n.d.). A woman that is pregnant with an eligible Indians child can receive health services throughout her pregnancy and up to 6 weeks after. (U.S. Department of Health and Human Services, n.d.). However, if the parents are not married, the father must acknowledge paternity in writing or have it determined by the court.
As with many other government-sponsored plans, healthcare organizations can be affected by their participation with Indian Health Services. There are specific IHS facilities that exist, that obviously participate with the government entity. However, the extent and quality of services provided is not very comparable to that which one could receive at another facility or with better coverage. This is due to the lack of funding and the size of the population cared for compared to Medicare and Medicaid, for instance. Non-IHS facilities can see the same patients, but would receive a smaller reimbursement and may consequently deliver poor healthcare. Although Indian Health Services benefits those of the Indian/Alaska Native descent, healthcare is still a challenge for that population.
References:
Friedman, M. (2016, April 13). For Native Americans, Health Care Is A Long, Hard Road Away. Retrieved from https://www.npr.org/sections/health-shots/2016/04/…
Harrington, M. K. (2016). Health care finance and the mechanics of insurance and reimbursement. Burlington, MA: Jones & Bartlett Learning.
U.S. Department of Health and Human Services. (n.d.). Chapter 1 – Eligibilty for Services | Part 2. Retrieved from https://www.ihs.gov/IHM/pc/part-2/p2c1/#2-1.2
Post # 2
RE: Discussion – Week 2
Workers Compensation is a government-sponsored plan that has significant importance. According to the United States Department of Labor (n.d.), the Mission of the Workers’ Compensation Programs is to protect workers who are injured or become ill on the job, their families and their employers by providing payment of benefits and helping wounded staff return to work as soon as possible. The benefit ensures payment for any necessary treatment needed for a fall, injury, or sickness derived from working conditions or while working will, by law, be covered by the workers compensation insurance instead of out of pocket or through the victims health insurance which can become a financial burden. Any incidents should be reported instantly to a supervisor or member of management and claims filed immediately as a means of preventing a delay in treatment and reimbursement of care.
Workers compensation offers five primary benefits which are medical care, temporary disability if wages are lost due to the injury, permanent disability benefits is the victim does not fully recover completely, supplemental job displacement benefits for retraining and skill enhancement, and death benefits that are payable to dependents including spouses if the illness or injury results in death (Department of Industrial Relations, n.d.). The employee is entitled to payment of medical care and lost wages regardless of who was at fault for the illness or injury as long as the employee is eligible for the benefit. The four rudimentary eligibility requirements for workers compensation benefits are a current employee of the employer, the employer must carry workers compensation insurance, the injury or illness must be work-related, and the states deadlines for reporting and filing a claim for the injury or illness must be adhered (United States Department of Labor, n.d.). If the requirements are not met, no benefit can be received by the victim; even if all other requirements are met, if the timeframe for reporting and filing is missed the right to receive compensation will be compromised.
Employers can seek workers compensation coverage through their state s non-profit compensation fund which provides affordable coverage for small and large businesses (Harrington, 2016). Lack of participation of workers compensation can be detrimental to an affected employee. Non-coverage can impact the reimbursement expected by healthcare organizations that provide care to victims presenting with work-related injuries and illnesses. If the patient does not have an eligible workers compensation claim, they will be required to use personal health insurance or pay out of pocket. Due to the cost of healthcare services, out of pocket payments may not be received promptly or at all resulting in non-payment for services and treatment rendered to a patient. References
Department of Industrial Relations (n.d.). Workers Compensation. Retrieved from https://www.dir.ca.gov/dwc/WCFaqIW.html
Harrington, M. K. (2016). Health care finance and the mechanics of insurance and reimbursement. Burlington, MA: Jones & Bartlett Learning.
United States Department of Labor. (n.d.). Office of Workers’ Compensa
Unformatted Attachment Preview
BACKGROUND
The Centers for Medicare and Medicaid Services (CMS) administer the Medicare
program. CMS employs Medicare contractors, including Wisconsin Physicians Service
(WPS), to process and pay hospital outpatient claims using the Fiscal Intermediary
Shared System (FISS).
CMS implemented an outpatient prospective payment system (OPPS) for
hospital outpatient services. Under the OPPS, Medicare pays for hospital outpatient
services on a rate-per-service basis that varies according to the assigned ambulatory
payment classification group. Under the OPPS, outlier payments are available when
exceptionally costly services exceed established thresholds.
Common medical devices implanted during outpatient procedures include
cardiac devices, joint replacement devices, and infusion pumps. Generally, a provider
implants only one cardiac device during an outpatient surgical procedure. Under the
OPPS, payments to hospitals for medical devices are packaged into the payments for
the procedures to insert devices. Hospitals are required to report accurately the number
of device units and related charges on their claims. The failure to report accurately the
device units and related charges could result in incorrect outlier payments.
Our audit covered $32,860 in Medicare outlier payments to hospitals for 14
claims for outpatient procedures that included the insertion of more than one of the
same type of medical device. The 14 claims had dates of service during calendar years
(CY) 2008 and 2009.
OBJECTIVE
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Our objective was to determine whether Medicare paid hospitals correctly for
outpatient claims processed by WPS that included procedures for the insertion of
multiple units of the same type of medical device.
SUMMARY OF FINDINGS
Of the 14 claims that we reviewed, Medicare correctly paid eight outpatient
claims processed by WPS that included procedures for the insertion of multiple units of
the same type of medical device. However, for the remaining six claims, Medicare did
not pay hospitals correctly. These incorrect payments were due to hospitals overstating
the number of units and related charges, resulting in excessive or unwarranted outlier
payments.
For the six claims, WPS made overpayments to hospitals totaling $17,996.
Incorrect payments occurred because hospitals had inadequate controls to ensure that
they billed accurately for claims that included the insertion of medical devices. In
addition, Medicare payment controls in the FISS were not always adequate to prevent
or detect incorrect payments.
© 2018 Laureate Education, Inc.
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References:
Nursing Standards
Nursing and Midwifery Board of Australia. (2018). Code of conduct for midwives. https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx
Clinical Guidelines
Guideline Adaption Committee. (2016). Clinical practice guidelines and principles of care for people with dementia. NHMRC Partnership Centre for Dealing with Cognitive and Related Function Decline in Older People. https://cdpc.sydney.edu.au/wp-content/uploads/2019/06/CDPC-Dementia-Guidelines_WEB.pdf
Living Guideline
Stroke Foundation. (2022). Australian and New Zealand living clinical guidelines for stroke management – chapter 1 of 8: Pre-hospital care. https://app.magicapp.org/#/guideline/NnV76E
Evidence-based practice
BMJ Best Practice
Goldfarb, S., & Josephson, M. (2020). Cystic fibrosis. BMJ Best Practice. https://bestpractice.bmj.com/
Schub, T., & Cabrera, G. (2018). Bites: Head lice [Evidence-based care sheet]. Cinahl Information Systems. https://www.ebscohost.com
Beyea, S. C., & Slattery, M. J. (2006). Evidence-based practice in nursing: A guide to successful implementation. http://www.hcmarketplace.com/supplemental/3737_browse.pdf
JBI: Evidence summary
Swe, K. K. (2022). Blood glucose levels: Self-monitoring [Evidence summary]. JBI EBP Database. https://jbi.global
JBI: Best practice information sheet
Bellman, S. (2022). Experiences of living with juvenile idiopathic arthritis [Best practice information sheet]. JBI EBP Database, 24(1), 1-4.
Cochrane Database of Systematic Reviews
Srijithesh, P. R., Aghoram, R., Goel, A., & Dhanya, J. (2019). Positional therapy for obstructive sleep apnoea. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD010990.pub2
Drug Information
Codeine. (2023, January). In Australian medicines handbook. Retrieved February 2, 2023, from https://amhonline.amh.net.au
Colorado State University. (2011). Why assign WID tasks? http://wac.colostate.edu/intro/com6a1.cfm
Dartmouth Writing Program. (2005). Writing in the social sciences. http://www.dartmouth.edu/~writing/materials/student/soc_sciences/write.shtml
Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice? [Abstract]. Online Journal of Issues in Nursing, 13(1). http://ojin.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Health-IT/StandardizedNursingLanguage.html
Wagner, D. (n.d.). Why writing matters in nursing. https://www.svsu.edu/nursing/programs/bsn/programrequirements/whywritingmatters/
Writing in nursing: Examples. (n.d.). http://www.technorhetoric.net/7.2/sectionone/inman/examples.html
Perth Children’s Hospital. (2022, April). Appendicitis [Emergency Department Guidelines]. Child and Adolescent Health Service. https://www.pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Appendicitis
Department of Health. (n.d.). Who is being active in Western Australia? https://ww2.health.wa.gov.au/Articles/U_Z/Who-is-being-active-in-Western-Australia
Donaldson, L. (Ed.). (2017, May 1). Healthier, fairer, safer: The global health journey 2007-2017. World Health Organisation. https://www.who.int/publications/i/item/9789241512367
NCBI Bookshelf
Rodriguez Ziccardi, M., Goyal, G., & Maani, C. V. (2020, August 10). Atrial flutter. In Statpearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK540985/
Royal Perth Hospital. (2016). Procedural management: Pre and post (24-48 hours) NPS. Canvas. https://courses.ecu.edu.au
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