Understanding Payment Systems in Healthcare

School: Southern New Hampshire University - Course: HCM 345 - Subject: Accounting

4-2 Journal: Payment Systems Angalique Reedy HCM 345 Healthcare Reimbursement Southern New Hampshire University 30 January 2021

4-2 Journal: Payment Systems 2 The Health Insurance Portability Accountability Act (HIPAA) is separated into five sections. In the section that HIPAA and the addition of Administration Simplification (AS) to a portion of the SSA, it sets up procedures for codes used in medical billing and coding (MB&CC, n.d..). The regulations are used to prevent abuse and fraud in medical billing and coding departments. HIPAA regulates and protects all electronic transfers of patient information and financial transactions, which provide a straight line into the reimbursement process. HIPAA not only help to mandates that anyone use a form of electronic data to transfer the use of same identifiers, code set and healthcare transactions, that allow the PPS to identify payment types (MB&CC, n.d.). The Affordable Care Act (ACA) was an initiative presented with no limit on care, which means insurance companies cannot dictate the amount of care a person received during a year, which meant providers could bill more. In some area's reimbursement went up in some demographics such as specialty providers (Clark, n.d.). providers who offer specialty care receive high a turnout in reimbursement due to the care they provide. Prospective Payment Service (PPS) is a reimbursement which Medicare payments are paid on a fixed sum, depending on the classification system for each service. The diagnosis related groups (DRG) is for patient hospital services reimbursement, while the Center for Medicare & Medicaid Services (CMS) uses a different PPS for reimbursements of home health agencies, hospice, hospital outpatient and long-term care (CMS.gov, 2019). The effects that regulations have on PPS by creating more accurate codes for billing help to reduces errors. PPS makes it affordable by using a fixed amount. I've worked slightly in the in the coding or billing department, mostly due to the management position I worked in, with 8 medical providers being somewhat knowledgeable in

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4-2 Journal: Payment Systems 3 billing and coding is important. I was responsible for ensure that encounters were processed daily as well as reconciling each visit in the system to capture correct patient classification and patient information. How the military medical system works with the EMR, and processing physician notes to make sure any procedures associated with that visit is captured during billing and coding, this system can provide CPT code along with laboratory billing codes. If for some reason these requests are not coded correctly or accurate the system will alert provider to be corrected or re inputted. Once the codes are cleared the encounter will be submitted for reimbursement. PPS has made it easy to file claims and processed in an appropriate manner making the reimbursement.