DUE THURSDAY – ORIGINAL WORK ONLY

This week, let’s engage in discussion about reimbursements. Remember that an active discussion is the key to an interesting and engaging online course. This can be somewhat dense material at first, so it is important that you read what others have written and then add substantively to the discussion. It is important to start the discussion at the beginning of the module to ensure that the discussion has been exhausted before moving on to the next module.

As you progress through the discussion, be sure to refer back to the assigned readings for this module. 

Please note that the first question allows you to consider what you have learned to date and any of your experiences in a health care organization or other workplace to get started. As you progress, you will need to meaningfully apply the readings, using APA 6 formatting for any citations. Remember that the week will go by very quickly, so start early! 250 words for each question.

Please discuss the following questions over the course of this week.

1. The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) currently leads the fight against waste, fraud, and abuse by health care industry providers. Based on what you have learned to date in this course, if you were a manager in a health care organization and responsible for compliance, what would you do if you uncovered fraudulent billing in one of your departments? What would be your systematic action plan to resolve this issue?
2. You are managing a private multi-physicians group and two of the physicians want to change X for a new ambulatory surgical procedure while the two other physicians want to charge Y for the same procedure. They call you in to break the tie. However, when you question the four of them about how they decided on X or Y, they only shrug their shoulders, saying they chose X or Y, arbitrarily. As the manager, what information about pricing services would you share with the physicians? How would you help them make an informed decision about the pricing of this new procedure?
3. After you have read, Acute Care Hospital Inpatient Prospective Payment System from your readings, reflect on what you think is the single most important factor of Prospective Payment Systems and why? You will likely find significant diversity in one another’s responses. Reflect with one another on your choices and why you think your choices in PPSfactors may have differed.

READING/ sources

• Module Notes: Payment Systems: How are providers reimbursed?
• Baker & Baker Text – Chapter 5 (pgs. 44-46) Section on grouping expenses for planning and control for reimbursement information.
• Dong Yeong, S., Menachemi, N., Diana, M., Kazley, A., & Ford, E. W. (2012).Payer mix and EHR adoption in hospitals. Journal Of Healthcare Management, 57(6), 435-448.
• Edwards, N., & Honemann, D. (1994). Refinement of the Medicare diagnosis-related groups to incorporate a measure of severity. Health Care Financing Review, 16(2), 45. Historical information
• Hackbarth, G. M.(2013, March 13). Report on Medicare Payment Policy. FDCH Congressional Testimony. (Review this to be familiar with resource)
• Office of the Inspector General. (2010). Some questions compliance professionals should ask as they prepare for health care reform: Excerpt from keynote address delivered by Daniel R. Levinson, Inspector General for the Department of Health and Human Services, at the Health Care Compliance Association’s Annual Compliance Institute on April 19, 2010 [PDF file size 30.2 KB].
• Read the following Center for Medicare and Medicaid pages to acquire knowledge on reimbursements to providers, prospective payment systems, physician fee schedules, and fee schedule searches: