The Business of Healthcare: Billing, Policy, and Insurance

Medicare

• Federally funded program primarily for older adults.
• Also covers people with certain disabilities and conditions like end-stage kidney disease.

Four Parts of Medicare:

• Part A:
  • Covers inpatient care, including hospitalizations, hospice care, and skilled nursing facilities.
• Part B:
  • Covers outpatient care, diagnostic tests, and medical equipment.
• Part C:
  • Medicare Advantage Plan.
  • Bundles extras like dental, hearing, and vision coverage.
• Part D:
  • Focuses on prescriptions.
  • Mnemonic: Part D for Drugs.

Medicaid

• Jointly funded by federal and state governments.
• Rules vary by location as each state sets its own income eligibility criteria.
• Designed for individuals and families with limited income.
• WIC (Women, Infants, and Children) is an example of how Medicaid extends benefits to specific groups needing extra support.

Children's Health Insurance Program (CHIP)

• Ensures that children and families earning too much to qualify for Medicaid but who still need assistance don't go uninsured.

Reimbursement for Nurse Practitioners

• Tied back to two key legislative acts: BBA and BRA.

Budget Reconciliation Act (BRA)

• BRA enabled nurse practitioners to bill for their services.
• Mnemonic: BRA is like a thing you put on in the morning.

Balanced Budget Act (BBA)

• Introduced the requirement for an NPI number for billing.
• NPI (National Provider Identifier) is a unique identification number assigned to each clinician and is necessary for submitting claims for insurance billing.

Incident-To Billing

• Scenario: A physician evaluates a patient and sets up a plan of care, and then the NP takes over the patient's follow-up visits for that same issue.
• Under this Medicare provision, the NP can bill these follow-up services under the physician's NPI.
• With incident-to billing, the practice receives full reimbursement at 100% of the physician fee schedule instead of the usual 85% when billed under an NP's NPI.

Rules for Incident-To Billing:

• The physician must have initially seen the patient and established the plan of care.
• The physician must be present in the building during the NP's visit with the patient.
• There needs to be a direct continuity of the plan of care set by the physician.
• If the patient reports a new problem during the NP's visit, it no longer qualifies for incident-to billing.
• Thorough documentation is key.

Billing Codes

ICD-10 Codes

• Stands for International Classification of Diseases.
• Describe the specific diagnosis or condition being treated.
• Example: E11.9 is the code used for type two diabetes without complications.

CPT Codes

• Stands for Current Procedural Terminology.
• Codes for the procedures and services performed during the visit.
• Covers lab tests, x-rays, and other procedures.

E and M Codes

• Stands for Evaluation and Management.
• Based on the level of medical decision making.
• The depth of medical decision making depends on the reason for the visit (acute, problem-focused vs. routine check-in for chronic conditions).
• Documentation should provide a clear picture of the assessment and justify the codes and game plan for the patient.

Healthcare Policy

HITECH Act

• Law that mandates the use of electronic medical records.

Meaningful Use

• Defines how to use technology effectively to benefit patient care.
• Example: Receiving a visit summary after a medical appointment.

Clinical Decision Support

• Helps clinicians quickly identify critical patient data.

• Example: Abnormal labs or vital signs highlighted in red in the EMR.

• Strengthens the protection of health information (PHI), keeping sensitive patient data secure.

Affordable Care Act (ACA)

• Enacted in 2010.

Section 1557

• Non-discrimination provision enforced by the Office for Civil Rights.
• Ensures that no one is denied care based on their race, color, nationality, age, disability, or sex.
• Mandates that clinicians provide language assistance to patients who are not fluent in English.

Genetic Information Nondiscrimination Act

• Prevents the misuse of genetic information in health care insurance decisions and employment.
• Protects individuals from discrimination based on their genetic data.

COBRA (Consolidated Omnibus Budget Reconciliation Act)

• Designed to bridge gaps in health coverage for individuals who've lost or left jobs.
• Allows individuals to continue using their existing health care plans, but they take on the full cost of the premium (what they were paying before plus what their employer used to cover).
• Coverage can be extended up to 18 months after leaving their job.

Healthcare Organization

Three-Tiered Cake Model:

• Primary Care:
  • Base layer.
  • Includes preventative checkups, vaccinations, health advice, and health maintenance for chronic conditions.
• Secondary Care:
  • Middle layer.
  • Specialists (e.g., cardiologist, orthopedic surgeon) take over when a specialized opinion or intervention is needed.
• Tertiary Care:
  • Top layer.
  • Highly specialized and includes intensive care, cancer treatment, neurosurgery, and burn treatment.

Healthcare Delivery Systems

• HMOs (Health Maintenance Organizations):
  • Exclusive club where you pay a membership fee for comprehensive care.
  • Requires choosing a primary care provider who acts as a gatekeeper for seeing specialists.
  • Usually means lower out-of-pocket costs but less flexibility.
• PPOs (Preferred Provider Organizations):
  • Gives you more freedom to see any clinician without a referral.
  • Results in a higher premium but more flexibility.
  • Seeing an out-of-network clinician will cost more.
• Patient-Centered Medical Home (PCMH):
  • Focuses on care coordination and comprehensive care, ensuring all aspects of a patient's health are addressed holistically under one roof.
  • Primary care provider coordinates with all other services to ensure efficient, effective care that respects patient preferences and needs.
• Third-Party Administrators (TPAs):
  • Handle the administration of health insurance plans and patient claims, ensuring the financial aspect of the health care system runs smoothly.

Telehealth

• Involves using technology to provide healthcare services remotely.
• Great for routine follow-ups and for patients living in rural areas to reduce travel time and costs.
• Clinicians must be licensed in the state where the patient is located.
• HIPAA rules still apply, and a secure platform must be used.
• Insurance companies have expanded reimbursement policies for telehealth services.

Regulation and Safety

The Joint Commission

• Accredits and certifies healthcare organizations, ensuring that they meet specific standards of care and safety.

Sentinel Event

• A major patient safety event that resulted in severe or permanent harm to a patient or even death.

Root Cause Analysis (RCA)

• An investigation to find out not just what went wrong, but why.
• Involves reviewing patient flow, staff actions, and communication during the event.
• Aims to prevent similar errors in the future.