Discussion: Participation in Government-Sponsored Plans

Consider the following scenario:

Mosaic Internal Medicine is a small group practice with three physicians. Over the past year, the practice has experienced declining revenues despite an increase in the number of patients. After careful review of financial statements, it is determined that much of the decrease in income is due to Medicare reimbursement. Specifically, the audit revealed a high number of claim denials due to improper billing procedures. Additionally, the practice has no limit on the number of Medicare patients they accept, which is one of the reasons for the noticeable increase in the number of patients over the past few years. In other words, more baby boomers are entering the Medicare system and needing medical service.

Medicare’s low reimbursement rate coupled with an increase in the number of Medicare patients can lead to declining revenues for many providers, which is why many doctors are refusing to accept Medicare payment for services (Moffit, 2002).

The practitioners at Mosaic Internal Medicine have a tough decision to make about how to handle the situation. They can limit the number of Medicare patients they see or stop accepting Medicare all together. They can also provide more in-depth training for their staff to ensure that Medicare claims are submitted properly.

Imagine that you are the healthcare manager for Mosaic Internal Medicine. It is your responsibility to ensure the overall profitability of the practice as well as the overall satisfaction of patients and their experiences. How would you approach the situation? What would be your first course of action? Keep these questions in mind as you consider this week’s Discussion.

This week you will examine different types of government-sponsored healthcare plans and their impact on healthcare organizations. You will also be introduced to claims processing, which has many rules and regulations that must be followed to maintain cash flow for a healthcare facility. A more in-depth look at claims processing as it relates to compliance and revenue cycle management will be addressed in future weeks.

Reference: Moffit, R. (2002). Why doctors are abandoning Medicare and what should be done about it. Retrieved from https://www.heritage.org/health-care-reform/report/why-doctors-are-abandoning-medicare-and-what-should-be-done-about-it

Discussion: Participation in Government-Sponsored Plans

More than one fourth of all healthcare services are paid by the federal government, making it “the largest single payer of health care in the United States” (Troy, 2015, p. 1). For providers, dealing with the nation’s largest payer requires a deep understanding of the different government-sponsored plans in terms of coverage, rules, and regulations related to care and payment for services (Harrington, 2016). Because there are so many options for coverage and payment, it is important for the healthcare administrator to understand proper billing procedures to help maintain the financial health of the organization he or she represents.

In this Discussion, you examine different government-sponsored healthcare plans and then discuss how participation in these plans impacts healthcare providers.

References: Harrington, M. K. (2016).  Health care finance and the mechanics of insurance and reimbursement. Burlington, MA: Jones & Bartlett Learning.

Troy, T. D. (2015). How the government as a payer shapes the health care marketplace. Retrieved from http://www.americanhealthpolicy.org/Content/documents/resources/Government_as_Payer_12012015.pdf

To prepare for this Discussion:

• Review this week’s Learning Resources.

• Choose one of the following government-sponsored plans on which to focus for this Discussion:

◦ Medicare

◦ Medicaid

◦ Children’s Health Insurance Program

◦ TRICARE

◦ CHAMPVA

◦ Worker’s Compensation

◦ Indian Health Services

• Review the assigned chapters from Harrington (2016) and review the Centers for Medicare and Medicaid Services (CMS) homepage for information on the plan you chose.

• Find at least one current, reputable online source (e.g., .org, .edu, .gov, or .mil) that discusses the challenges providers face regarding government-sponsored plans such as in the example of Mosaic Internal Medicine in this week’s Introduction. These could be financial challenges, quality of care issues, constantly changing rules and regulations, or any other challenge you may find.

By Day 4

Post a comprehensive response to the following:

• Identify and describe the basic characteristics (e.g., the beneficiaries, services covered, who administers it, etc.) of the plan you chose.

• Outline the eligibility requirements for coverage for the targeted population.

• Discuss how participation (or lack of participation) in the plan impacts healthcare organizations.

Provide specific examples in your response. Support your post with the Learning Resources and at least one outside scholarly source.

Required links:

https://www.cms.gov/About-CMS/Agency-Information/History/index

https://www.cms.gov/

https://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/SystemAccess