Healthcare Reimbursement Chapter 3 discussion

In your post, compare and contrast various payers and suppliers and the claims filing process.
How important are ethics with claims processing? Explain how ethics can impact payer mix and
reimbursement.
The payers associated with reimbursement of healthcare services are government and
commercial payers. These entities ensure that out-patient, in-patient, professional, and nonpatient services are processed according to state regulations and laws. The largest payers are
Medicaid and Medicare. Medicare is composed of several plans all offering different coverage.
These plans are Medicare part A,B,C and D. Medicare Part A is insurance based on employment.
Medicare Part B insurance covers for services, supplies, and drugs administered to patients by
inpatient or outpatient healthcare organizations. Medicare Part C insurance covers health
maintenance organizations (HMOs), provider sponsored organizations (PSOs), and local
preferred provider organizations (PPOs) (Harrington 2016, p. 82). Medicare Part D insurance
provides access to prescriptions at a lower cost. Other forms of government insurance include
TRICARE and CHAMPVA which provide health coverage for military service members and
their families. TRICARE has many options available to its service men and women. TRICARE
Prime covers a comprehensive amount of service such as emergency, in-patient, out-patient,
hospitalizations, and preventative care. Standard provides a fee-for-service plan to nonactive
service members in the U.S. Service members must be registered in DEERS to maintain
enrollment. Finally, TRICARE for life offers secondary coverage to all Medicare beneficiaries
who have both Medicare Part A and Medicare Part B. This coverage is available worldwide and
Tricare is the primary payer. (Harrington 2016, p. 88). Workers compensation is used to help
employees cover their medical expenses based on a work related injury. Other types of insurance
include the State Childrens Health Insurance Program (CHIP) and the Programs of All-Inclusive
Care for the Elderly (PACE). The CHIP form of insurance provides health coverage to children
of low income households who do not qualify for Medicaid. The children and families who do
not fit specific guidelines of the program may not be eligible for coverage. These children must
fall below the 200 percent of the Federal Poverty Level. The PACE program helps to provide
comprehensive care to elderly. This also consists of social work services. The patient must be
55 years of age or older, meet a Nursing Facility level of care, and live in the network servicing
area for the PACE organization (Harrington 2016, p. 86). A supplier according to Harrington
(2016), is a physician, or other practitioner, or an entity other than a provider that furnishes
healthcare services under Medicare (p. 47). A supplier must meet the guidelines of the Medicare
Program Integrity Manual. Providers who work in a capacity that meets supplier guidelines must
enroll and bill Medicare separately as such.
A claim is submitted to a third-party organization for payment of services. All information
provided on the patient health record must be used to complete the claim. According to
Harrington (2016), there are two forms of claims. These are institutional and professional (p.
47). The two forms used in the process of claims are the CMS-1500 and the CMS-1450. The
CMS-1500 form is used to process physician and outpatient services. The CMS-1450 is used to
submit charges from the facility in which services were rendered to a patient. An institutional
claim is submitted using the Health Insurance Portability and Accountability Act (HIPAA). The
claim must be submitted using the ASC X12N 837 form. Forms may be submitted electronically
or through paper. The UB-04 is the paper form used in institutional claims. The professional

claim must be submitted using the ASC X12N 837 or CMS-1500 as the paper alternative. The
institutional claim form has far more sections than the professional claims form. There are
approximately 81 sections.
Ethics should most definitely be adhered to when completing claims. Many healthcare
organizations live by ethical values which determine whether the organization will succeed or
not. Healthcare facilities are working in a business that aims to help and do no harm. Claims
must be filled out entirely and accurately. Healthcare professionals and coders adhere to state,
federal, and government rules with regards to submission of claims forms. When these
guidelines are not adhered to laws become broken. As a result, the organization can be sued, lose
its license, and worse off be shut down.
Ethics impacts every aspect of healthcare and billing. Consumers of healthcare want affordable,
reliable, and high quality medical services rendered to them. A big issue in healthcare ethics is
cost containment. Cost containment services related to healthcare should in no way affect the
delivery of care. Creating better streamlined billing services and bundled payments can help cut
costs associated with healthcare and also create a better rapport with customers (ACEP).
Insurance companies should be more involved in the ethical aspect of healthcare because without
consumers they would not exist. These companies should provide incentives to healthcare
organizations who are creating programs for patient safety and coordination. Ethics applies to
every aspect of healthcare including billing. Coders and billers should perform their duties
ethically to ensure the patient as well as the organization doesnt suffer. Insurers and third party
payers should present other opportunities for consumers to access out of network providers.
Being restrictive tends to leave patients at a disadvantage. When patients are given options to
who and where they can be seen, they are happier and feel in control of their lives. Sometimes
providers do not have the ability to send patients to the best healthcare facilities because of payer
constraints. This poses as a negative ethical impact on healthcare.
Reference
ACEP. (n.d.). Retrieved April 25, 2016, from
https://www.acep.org/PhysicianResources/Practice-Resources/Professionalism/Ethics/The-Ethics-of-Health-Care-Reform-Issues-in-Emergency---Medicine---An-Information-Paper/
Harrington, M. K. (2016).
Healthcare Finance: and the Mechanics of Insurance and
Reimbursement
. Burlington, MA: Jones & Bartlett Learning