Medicare severity diagnosis-related group or MS-DRG is Medicare refinement to the diagnosis-related group (DRG) classification system, which allows for payment to be more closely aligned with resource. The Medicare Severity-DRG (MS-DRG) is the most commonly used DRG system, because it governs the ever growing ranks of Medicare patients (Bushnell, 2013).…
This is a second Medicare compliance determination. The initial compliance determination was made by EHR which felt the patient should be observation status. Dr. Neilian disagreed. My clinical review of the chart reveals that the patient is 89-years of age, she presented with shaking, chills, fever of 103 and hematuria. Her medical history is significant for a previous history of right breast cancer, chronic acquired lymphedema, as well as hypertension. Her initial labs showed her to have an elevated white blood count and left shift, as well as a positive blood culture growing E coli. I believe that this patient represents acute inpatient admission. She requires IV antibiotics so I concur with the attending physician Dr. Neilan who believes…
* It is very important that a patient understands that their coverage does not pay for the service that they are trying to receive. If the provider just went ahead and seen the patient knowing that their insurance did not cover them and then proceed to charge the patient the full amount on the bill, I think they could get into trouble. The…
Created by Congress in 1965, under President Lyndon B. Johnson, Medicare is an insurance program sponsored by the United States government. The purpose of Medicare is to guarantee access to health insurance for US citizens of age 65 and over and to people of any age with disabilities. In 2011, 48.7 million people were covered by Medicare with a total expenditure of $549.1 billion1 from which $182.7 billion was used to cover 15.3 million inpatient admissions; this represents 47.2 percent of total hospital’s admission costs in the US. Medicare falls under the category of a single-payer health care program;2 which means that a single public or semi-public agency organizes the healthcare finances; however, the delivery of care remains under private authority.…
Medicare is a federal program that pays certain health care expenses for people aged 65 or older, and individuals who are deemed disabled by the Social Security Administration. Enrolled individuals must pay deductibles and co-payments, but much of their medical costs are covered by the program. Medicare is less comprehensive than some other health care programs, but it is an important source of post-retirement health care.…
If you are getting close to the age when you become eligible for Medicare, you need to understand how Medicare Supplement insurance works. Medicare Supplement insurance is often referred to as Medigap insurance. It is designed to fill in where Medicare Part A and B leave off and fill in the ‘gaps’ in your coverage.…
Diagnosis related groups (DRGs) have been around since the early 1980s, evolving over the years as a patient classification system. However, since October 1st, 2007, Medicare relies on the Medicare Severity-Diagnosis Group (MS-DRG) system to facilitate payments of services rendered for Medicare inpatients.…
The three primary steps to establishing financial responsibility for insured patients are verifying the patient’s eligibility for indemnity benefits, determining pre-authorize and referral requirement, and determining the main payer if more than one indemnity plan is within effect. There are three factors that ascertain patient benefits eligibility. These factors are coverage might cease on the concluding day if the month within which the employees active full-time service is concluded, such as terminus, furlough, or disablement. The employee might no longer measure up as a member of the group. For exemplar, roughly companies do not furnish benefits for part-time employees. If a full-time employee alters to part-time employment, the coverage ceases. An eligible dependent’s coverage might cease on the concluding day of the month within which the dependent status ceases, such as making the age boundary stated within the policy (p. 90). Whenever an insured patient’s policy does not cover a planned service, such situation is talked about with the patient. Patient’s are to be informed that the payer does not pay for the service and that they are creditworthy for the charges. Some payers expect the doctor to use particular forms to tell the patient regarding uncovered services. These financial agreement forms, which patients must pre-indications demonstrate that patients have been told about their responsibility to devote the bill before the services are applied. For exemplar, the Medicare plan furnishes a form, called (ABN) - advance beneficiary notice that must be used to demonstrate patients the billings. The contracted form, allots the practice to compile defrayment for a furnished service or append directly from the patient if Medicare declines reimbursement (p.…
Medicaid and Medicare have been around for more than 50 years, when President Johnson signed them into effect. Medicare helps people 65 or older, younger people with disabilities and people with end stage renal disease. Medicaid is a federal-state health insurance for people with low income or disabled. These programs have helped several people pay for hospital bills/visits. The Affordable Care Act also known as Obamacare was first put into effect in 2010, by President Obama. Its promise was to expand coverage and make insurance available to Americans who have not been able to receive insurance. There has been a great debate since it first went into effect, whether it was a good decision or bad. In this paper I will evaluate the pros and cons,…
There are a sum of factors that determines whether or not if a patient is eligible for health care benefits such as premiums not being paid accordingly, employment changes, and sudden changes with the health coverage. There may also come a time when the insured patient's insurance doesn't cover the cost of a planned service. In the matter of this event happening the patient will be informed that their insurance payer will not be covering the cost of the planned services, and that they will personally be responsible. Sometimes the insurance provider will require the health provider to inform the patient of this matter through a written form that must be signed by the patient to verify their understanding that they are responsible for the cost when their insurance isn't required to pay. The patient should always be aware of the services that are eligible to receive through their insurance so that there isn't confusion when it comes to paying for the services received. The health provider will determine what the insurance payer is entitled to pay, and then they will bill…
New restrictions placed on insurance companies under the Affordable Care Act dictate that insurance companies must spend 80% of collected premiums on patient care. These restrictions create a financial concern for insurance companies and their investors.…
Medicare is a government health insurance program. Medicare provides health care assistance for people 65 or older. Medicare provides insurance for people younger than 65 who have chronic illnesses, disabilities, or permanent kidney failure. Medicare will not cover all medical expenses, but it gives basic protection against some health care cost. Medicare beneficiaries are enrolled and giving specific information about insurance by the Social Security office. Medicare is divided into two parts. Medicare Part A which covers inpatient hospital. Medicare Part B which covers some doctors' bills and few health…
This paper is an overview of the Medicare system and how it works. The document is intended…
Thank you both for your comments. As you have both mentioned the Medicare rule for observation is very complex and confusing. The intention of the rule is to set clinical criteria for observation, and rapidly discharge the patient in twenty-four hours. However, this does not always happen. Some observation patients can stay up to ninety-six hours before being discharged or switched to observation status. One of the problems is individual health care organization interprets the Medicare rule differently. Then if the patient had a managed care Medicare carrier, the rules may be different. This makes observation status for an organization nightmare to manage (Hockenberry, Parlato, & Ross, 2014). What I find even worse, observation increases the…
In 2010, President Obama enacted the Affordable Care Act. It place health insurance reforms which makes health care more affordable. It allows people to be in charge of their healthcare. This act has benefits for women, young adults, seniors, businesses, and pretty much everyone. It has many benefits such as providing protection against Health Care fraud, holding insurance companies accountable, consumer protections, improving and lowering healthcare costs, and allowing easier access to health care. It provides many benefits and people are more likely to go to the doctor when they really need to. As we all know, it can be costly to go to the doctor. For that reason, people usually put it off as long as possible, which may only worsen their…