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The Council for Affordable Quality Healthcare, a nonprofit healthcare industry alliance that is helping drive payer collaboration and process consolidation through national, multistakeholder initiatives, is engaged in two initiatives that are producing real results in the marketplace today: the Committee on Operating Rules for Information Exchange CORE and the Universal Provider Datasource UPD.

This paper provides an overview of UPD and CORE as two examples of effective industry collaboration with a special focus on a recent study of the actual cost savings, benefits, and national implications of CORE certification. UPD replaces multiple organization-specific paper processes with a single uniform system for the collection of provider data that is used for a wide range of purposes including credentialing and provider directories.

Participating organizations report significant increases in the efficiency of numerous processes, including outreach to providers, data entry, application storage, and application turnaround time Figure UPD is used by over , providers and more than public and private organizations throughout the United States, with enrollment increasing by approximately 8, providers per month.

Use of the data is authorized only by the individual provider. Currently, 12 states have adopted the Council for Affordable Quality Healthcare Uniform Provider Credentialing application as their state standard.

Medicare vs Medicaid - What's the Difference?

Although the UPD was originally conceived as a credentialing tool for hospitals and health plans, its value as a data source for other uses is quickly growing. Kentucky has the first state Medicaid agency to participate in UPD for its provider enrollment efforts, with New York, Pennsylvania, Arizona, and Virginia Medicaid agencies now in active discussions.

The Council for Affordable Quality Healthcare is also piloting the use of UPD to enable providers to volunteer in the event of a large-scale emergency by allowing electronic forwarding of their data to designated state emergency responder registries. The Massachusetts System for Advanced Registration is the first such program to collaborate on this effort. In addition, hospitals are increasingly using UPD as an administrative simplification solution with almost 50 organizations currently participating.

Differences between Medicare and Medicaid

To address the interests of a range of different size hospitals, the Council for Affordable Quality Healthcare is working with natural aggregators such as the Vermont Association of Hospitals and Health Systems to encourage standardization of data collection for credentialing. Additionally, the Council for Affordable Quality Healthcare is studying the feasibility of expanding the UPD functionality to include a continuous primary source verification process.

There is potential for a game-changing approach to primary source verification that will eliminate the need for periodic recredentialing, while improving the quality, timeliness, and consistency of reported primary source data at a lower cost for the industry. CORE is developing and promulgating operating rules built on national standards, such as the Health Insurance Portability and Accountability Act HIPAA , that are facilitating administrative data exchange and promoting interoperability.

The vision of CORE is to enable provider access to healthcare administrative information before or at the time of service using the electronic system of their choice for any patient or health plan. Phase I rules target eligibility and benefits data to address the need for providers to receive actionable information when verifying patient coverage.

Who Pays for Long-Term Care?

Through subsequent phases, CORE is employing its operating rule concept to other administrative transactions in the claims process. Receiving this information electronically and in real time removes a key barrier to broader adoption of information technology by giving providers valuable information that affects their revenue cycle and creates a sustainable environment encouraging change.

Additionally, the average provider saw patient visit verifications increase by 24 percent while some doubled the number of patients verified. Results common across stakeholder groups include enhanced flow of information between providers and health plans, and the ability of stakeholders to leverage current infrastructure investments and streamline implementations with partners that are CORE certified Figure Results common to all stakeholders. The study analyzed eligibility-related data from 3 months prior to health plan CORE certification and 1 year after, including eligibility verification methods and volumes, claim rejections and denials, customer satisfaction, and cost of adoption.

Participants were from various stakeholder groups with all but some providers CORE certified, including national and regional health plans, clearinghouses, vendors, and providers representing 33 million commercial members and 30 million claims per month. Beyond phase I, CORE has established the industry structure for expanding the concept of operating rules across all administrative transactions, thereby significantly increasing the potential savings.

In fact, organizations can leverage the investment already made in CORE to support additional transactions and incorporate newer technologies such as swipe cards and real-time adjudication. As the partners of CORE-certified entities also begin to follow the rules, they can continue to shift transactions from proprietary solutions to standard real-time and batch electronic transactions.

Although the full capabilities needed for interoperability will take time to evolve into marketplace reality, real, lasting, and broad change can happen now. For example, many providers are already enhancing the eligibility process by moving to electronic transactions, creating streamlined electronic connections, modifying work flow, and training staff to take advantage of the improved information coming from CORE-certified health plans. The use of administrative data in the near and medium term represents an essential and available migration path to the eventual marriage of clinical and administrative data, providing visibility and transparency into the cost-effectiveness of high-quality healthcare services.

Until clinical data becomes more readily available, administrative data remains a key source of information with which to evaluate the progress toward a value-driven system. It can be used to support near-term population-level research priorities, to benchmark quality initiatives, and to support the growing adoption of electronic personal health records and electronic medical records. Administrative data also serves as part of the foundation needed to promote coordination of care across providers in a health information exchange. For example, market adoption of the CORE transport has enabled one-to-one exchange between providers and payers across the country, creating a basis for one-to-many data exchange relationships that is essential to the proliferation of interoperable systems.

In a study by the eHealth Initiative, eligibility inquiries represent some of the high transaction volumes within health information exchange efforts focused on clinical data interchange eHealth Initiative, For example, the CORE technical specifications gaining momentum in administrative data transport, also known as connectivity, were designed to be aligned with the Healthcare Information Technology Standards Panel specifications.

Both of these examples demonstrate the importance of integrating multiple approaches in order to advance adoption. Through agreement on a common transport and its related authentication and security, the full potential of the Internet to serve as a mechanism in changing health care moves closer to becoming a reality. Finally, administrative cost savings, such as those enabled by CORE, will help providers achieve the benefits they need to embrace the bigger vision of transforming the system since stimulus dollars alone will not be enough to fund the move to broader healthcare information technology needed in the care delivery process.

Cross-industry, public—private collaboration is a successful strategy for developing solutions with lasting change. UPD is saving millions of dollars for providers, and its established framework is now being considered as a vehicle for achieving additional industry-wide savings and quality improvements. CORE continues to expand operating rules built on national standards that are helping organizations achieve the interoperability that has eluded the healthcare industry for many years.

Continued collaboration focused on both short- and long-term goals, coupled with appropriate policy support through the federal government, is necessary to achieve the widespread adoption of administrative simplification solutions; solutions that promise real reform in both cost efficiency and quality. The nation is grappling with how to respond to the stark and disturbing realities of too little quality health care and too much waste.

This article identifies practical ways in which technology can save money by modernizing the administrative and transactional aspects of health care. Its focus is on savings across the healthcare system as a whole—savings that will initially accrue to physicians, hospitals, payers, and government—but ultimately to consumers of health care through reduced premiums, lower taxes, and improved diagnosis, treatment, and outcomes.

False Claims Act [31 U.S.C. § § 3729-3733]

Of these savings, approximately 50 percent would accrue to providers, 20 percent directly to government in its role as healthcare payer, and 30 percent to commercial payers UnitedHealth Group, These savings would likely benefit families and employers through lower healthcare costs. As importantly, they would simplify the lives of patients and eliminate much frustration on the part of doctors and hospitals.


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In this analysis, we limit the discussion to administrative savings, but several of the options raised here easily translate into medical cost savings and better health outcomes. The ideas in this article are supportive of industry-wide approaches to administrative simplification being advanced by others. While not intended as a comprehensive list of options, we believe the 12 approaches identified provide a strong foundation from which to advance an ongoing administrative simplification agenda.

The options we studied fall into three broad categories 11 :. In more detail, these three categories can be further broken down into 12 specific recommendations, summarized in Table The cost drivers targeted in each of these options include excessive manual processing, duplicate entry of data, paper distribution of transaction authentication and other information, use of intermediaries where they enable excessive process variation, administration associated with medical overpayments, and the costs of process proliferation. In each case, where individual options are interdependent or potentially overlap, we sought to account for possibly duplicative savings estimates.

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Further, each estimate is prepared net of the costs to administer each option. The necessary reforms for reducing administrative waste require a firm foundation. These new standards should also cover critical encounter data, such as care plan, lab results, conditions, and medication orders. A health information exchange could facilitate the sharing of this information in a fully secure, private environment.

The information will then assist care providers and health plans in engaging patients and coordinating care. From this foundation, a number of other reforms will be necessary and, in fact, are natural extensions of the new commitment to interoperability and connectivity. Consumers receive monthly health statements electronically instead of an explanation of benefits for each individual service. These systems require an information system infrastructure that is still far from a reality in most areas of this country.

The resulting system would support a few superregional hub gateways that aggregate payer connectivity and that provide gateways to direct provider connectivity or local geographic aggregator health information exchanges. These gateways would handle the full range of electronic connectivity for payers and could, in addition to providing administrative and financial functions, also provide clinical connectivity and analytics, surveillance, and other services.

A national predictive model prescoring service would actively monitor and flag claims prior to payment, leading to a more robust real-time adjudication process for most payments. This service, coupled with the establishment of a national payment accuracy clearinghouse, would reduce the instances of mispayment and administrative friction between payers and providers.

Using a single standardized process for accreditation and licensing nationwide would reduce costs for physicians and hospitals without compromising quality. The government could facilitate this process by creating an antitrust safe harbor allowing hospitals and health plans to agree on common rules and standards.

Anti-Kickback Statute [42 U.S.C. § 1320a-7b(b)]

An industry program would then be developed and deployed for provider credentialing. Similarly, we could accelerate the adoption of industry-wide rules and systems for data aggregation and measurement methodologies. Health plans and Medicare, working collaboratively with physicians, hospitals, and other key stakeholders, would agree on the infrastructures and processes necessary to efficiently pool local data across health plans and settings of care.

A new independent public—private partnership at the national level would lead and accelerate consistency in the processes necessary to achieve this and ensure uniformity across the country. As a result, physicians would be able to access, correct, and use their local aggregated data for performance improvement.

Researchers and others would benefit by using the aggregated data for tracking and developing quality improvement interventions.

Differences between Medicare and Medicaid - Medicare Interactive

Regarding performance measures themselves, and the methodologies underlying the process of performance measurement, there currently exists a useful infrastructure upon which to build e. Administrative programs can have important positive effects on reducing wasteful medical costs. Health plans—and self-insured employers—also spend administratively on a wide range of programs that provide patients information to support them in making informed choices, and that identify and offer incentives for best practices on the part of physicians and hospitals.

It follows that minimizing administrative costs should not be a public policy goal in isolation, and reform options for new programs should be assessed against their ability to tackle the well-documented problems of fraud, waste, and inappropriate use that affect U. Our experiences suggest that even where the technology exists and efforts have been made to introduce it, its full potential is not being realized. We believe that shared consistent action is now needed across all payers—commercial and governmental—in partnership with physicians and hospitals calling for tighter data and transaction standards, seamless health information exchanges, automated processes to replace antiquated manual systems, and standardization of such processes as credentialing and quality measurement.