Journal 4-1 Payment Systems

JOURNAL 4-1: PAYMENT SYSTEMS Journal 4-1: Payment Systems Healthcare organizations have a demand to meet all compliance, documentation, coding, billing, and reimbursement practices to perform properly. They have strict guidelines and governmental body regulations they must comply with to ensure that they will be reimbursed appropriately for the services being provided to the patients they are caring for. They are required to follow these guidelines, especially for billing and coding. Billing and coding guidelines are put into place to make sure patients are receiving the quality care from providers and that insurance companies are being billed appropriately. The coding and billing regulations that apply to Prospective Payment systems would be those such as, Diagnosis-Related Groups (DRGs), diagnoses codes ICD-10-CM, Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding (HCPCS) codes. The classification system for the Prospective payment systems is called the diagnosisrelated groups (DRGs). “The DRGs classify all human diseases according to the affected organ system, surgical procedures performed on patients, morbidity, and sex of the patient. The classification also accounts for up to eight diagnoses in addition to the primary diagnosis, and up to six procedures performed during the stay” (Office of Inspector General, 2001) . A better way to under this would be that when you are an inpatient status in the hospital, they assign you a DRG when you are discharged, creating it on the care you needed during your stay. The hospital in-turn gets paid a fixed amount for that DRG, regardless of how much money it actually cost the hospital to treat you as a patient. Ultimately, the best way to understand the payment process to the DRG’s is that “if a hospital can treat you for less money than Medicare reimburses for the DRG assigned, then the hospital makes money on that hospitalization. If the hospital spends more money caring for you than Medicare gives it for your DRG, then the 1 JOURNAL 4-1: PAYMENT SYSTEMS hospital loses money on that hospitalization” (Davis, 2020). These codes are mostly used for inpatient care settings and are required as being part of the Center for Medicare and Medicaid services. As a mentioned above, DRG’s include up to eight diagnoses in addition to the primary diagnosis, and up to six procedures performed during the stay; which requires the use of ICD10-CM and CPT codes. ICD-10 codes are 7 character and contain a category and category anatomic site/severity identification information, these are diagnosis codes that are given on a claim based on the providers documentation. These codes have helped clear up the quality of data that health insurance plans and organizations are receiving for reviewing accurate coding on claims for payment. The explanation and detail on the new codes “includes laterality, severity, and complexity of disease conditions, which will enable more precise identification and tracking of specific conditions (CDC, 2015). The advancements in coding help ease the medical terminology and classifications of disease types with those that match clinical practices. In addition to IDC-10-CM codes are the procedure codes which is the CPT coding system. A CPT code has four categories, including laboratory testing codes, are made up of 5 digits with no decimals and are special to a procedure a physician noted in the patient medical record. As stated by Trisha Torrey from Very well Health “Current Procedural Terminology (CPT codes) are numbers assigned to every task and service a medical practitioner may provide to a patient including medical, surgical, and diagnostic services. They are used by insurers to determine the amount of reimbursement that a practitioner will receive by an insurer for that service (Torrey, 2020b). If the codes to match up both IDC-10 and CPT codes with what the physician has noted in the patient’s chart this can cause an issue with the reimbursement process to the healthcare 2 JOURNAL 4-1: PAYMENT SYSTEMS organization. With these coding process and regulations put into place it allows for appropriate and timely billing to occur which in turn allows for payment to be rendered. One of the biggest challenges I see working for a health insurance company is that when we review claims we find two major issues, improper coding for services and bundled payment lagging the claims process down. When we review member medical records looking for completion of a health care gap we often find they either up-coded for a services they really didn’t document in enough detail to count or they under-coded and didn’t bill for the entire service they provided the member. We see this a lot in our pregnant population, when we review claims pro-actively. For members who know are identified as pregnant, we are finding they are not appropriately coding and billing for prenatal smoking sensation measures, appropriate treatment for follow up visits, etc. We also see that when a member is identified as being pregnant and they go see the OB-GYN after their first visit, all those subsequent visits are being bundled to the health insurance company. We know they were identified as pregnant but after that first claim, we only pay for all pre-labor visits bunded; DRG for the services. This sequentially hurts their quality measures when we find out a member had pregnancy induced diabetes after they delivered, we could have outreached to this member and supplied them with additional resources available to them such as home monitoring and education. I think revamping how this process of bundle billing and health insurance plans officer bundle payments for this type of healthcare need should be changed. We should be getting claims and bills for each visit had so we can stay up to date on the happenings of our health insurance members and use Case Management or the Pregnancy Special Needs Unit team where we can proactively rather than reactively reaching these members. 3