HCA- 240

HCA- 240 November 15, 2020 Professor Chip Coon Biller / Benefits Coordinator Interview In the healthcare sector, several functions are essential to a healthcare facility's functioning, but medical agents and coders are most important. It is the primary duty of medical coders and billers to examine patient medical notes and allocate the required diagnosis and treatment codes, also known as procedural codes. is a medical coder and biller aged 39 years and interviewed on November 12, 2020. Ann works for Northwestern Medicine Central DuPage Hospital, Illinois. She also supervises the coding of health departments and specializes in E&M codes for the emergency sector and also a medical co-coder (Personal Contact, November 12, 2020). The paper would also address the premiums variations between insurance funds, third- party insurances and Medicare / Medicaid, medical fees, and pricing systems. Payment System Variations The mechanism for charging for health care for each patient is different, and the charge for medical services is organized based on the status of the payment for each person as opposed to other types of trade. Ann described that cash payers are the simplest since there is no third- party insurance or subsidized insurance that the person must charge. The payment rate is also base on the health facility's regular service rates (Personal Contact, November 12, 2020). Payers from third parties are businesses that pay for a person's insurance expenses not funded by the government, for example, Cigna, United Health Care, Blue Cross Blue Shield, Etc. Sommers, Gawande, Baicker says, "the private insurer works under special terms, whether or not claim reimbursements are legitimate, which creates conflicting circumstances where a patient in a hospital compensate by an insurer that does not pay at another hospital" (Sommer, Gawande, Baicker, 2017). Additionally, a negotiated percentage of all charges based on a patient care plan used as the price-relates basis (Cleverley, Song, Cleverley, 2011). The compensation arrangement is base on a negotiated percentage of the overall charges. Finally, the government-funded payer Medicaid and Medicare are payers who pay a fixed rate or fee schedule set by the Medicaid and Medicare centers. Medicare / Medicaid also covers people who have minimal income and resources at medical expenses and payments already made regardless of the service costs rendered (the difference between Medicare and Medicaid, n.d.). It is also necessary for medical billers to know the billing and coding variations for the services provided between different payers. Pricing of the Healthcare Sector The medical industry produces an invoice of services and resources that include the costs and the fees following medical services provision. The 'prize' on the price list of a healthcare business is known as the CDM. Compared to other divisions, rates, or payments are the same for all regardless of payment status, Medicare and Medicaid are included (Cleverley Music, & Cleverley 2011, p.140). As described by Ann, the bill is comprehensive and includes International Classification codes for diagnosis and care by medical professionals and treated by billers and coders for diseases (ICD-10 codes). Billers and coders also must look at and check all information that is right and registered. Furthermore, billers/coders ensure the correct ICD-10 coding used before making insurance claims. When a claim filed, insurance claims were sent to the Clearinghouse for a clean claim; but, if a claim is rejected or resubmitted to the insurance provider, the reimbursement process may be slowed down (Personal Contact, November 12, 2020). For instance, a patient with ADD condition from a mental healthcare provider must not cover mental illness. The healthcare provider will have to accept a separate payment because it will not pay for the service. Payment delay can lead to a revenue loss because the patient does not pay for the visit. It also makes it one of the most complicated billing processes in the entire U.S. economy that the healthcare industry has in this phase. It is also critical for accountants and coders to know how the payment process ensures that the healthcare sector pays them. Reimbursement If the health provider approached by a specific private or governmental insurance firm, the premium rate for private and governmental insurance may depend on it. Reimbursement of health insurance has now become a dynamic payment system for facilities. Health facilities have arrangements with insurance providers and contribute periodically, and government payers adjust continuously to the complicated laws on the reimbursement of adjustments. Moreover, there is a maximum reimbursement rate that is payable for any CPT code and uses the reimbursement rates as a basis. Private healthcare service providers and hospitals negotiate a payment rate, but healthcare facilities will not allow patients whose insurance would no longer cover if an emergency is present (Torrey, 2020). Furthermore, public insurance agencies, including Medicare, Medicaid, Tricare, or Veteran Health Administration (VHA), are among the USA's most significant health insurance providers. Government repayment rates are "focused on the arrangement that Medicare or other government insurance companies are to pay for a specific benefit" (Healthcare Technology Advancement Implications of Reimbursement Policies & Practices. 2016). Also, it lets providers know what a health insurance corporation reimburses contracted Conclusion Finally, a medical coder is responsible for carrying out a particular procedure to help medical facilities in receiving patient care reimbursement from private and public bodies. Additionally, attention to each claim's specifics ensures that representations are correct since the claim can reject, and payment can postpone. Furthermore, how medical coders and billers do their job acknowledges the health organization's performance. Besides, the time and effort involved in medical examiners and coders ensure that medical claims are coded and reimbursed. Also, Ann interview gave very insight into the method of accounting and coding. References Cleverly W.O., Song, P.H., & Cleverly J.O. (2011). Essentials of health care finance. (7th ed.). Jones and Bartlett. Retrieved on 11 November 2020 from Sommers, B. D., Gawande, A. A., & Baicker, K. (2017, August 10). Health insurance coverage and health—what the recent evidence tells us. The New England Journal of Medicine, 6, 586. Retrieved on 11 November 2020 from https://search-proquest- The Impact of Reimbursement Policies and Practices on Healthcare Technology Innovation. (2016). United States Department of Health and Human Services. Retrieved on 12 November 2020 from Torrey, T. (2020, February 27). Understanding Healthcare Reimbursement. Very Well Health. Retrieved on 14 November 2020 from What is the difference between Medicare and Medicaid? (n.d.). United States Department of Health and Human Services. Retrieved on 13 November 2020 from