Running head: MEDICAL CLAIM REIMBURSEMENT

Annotated Bibliography: Medical Claim Reimbursement

MEDICAL CLAIM REIMBURSEMENT

Contents
Introduction..........................................................................................................................2

Sources.................................................................................................................................2

Brief description of the content and how it is relevant........................................................3

Analysis...............................................................................................................................7

Introduction

My area of practice in healthcare is project manager dealing with: Medical Claims

Reimbursements/Particular Medicare/Medicaid. My research work will explore the use of

alternative dispute resolution (ADR) in healthcare including the options for Bible based dispute

resolution, that will based on the issues raised in the usage of ADR to solve malpractice claims

limiting or without litigation. I have identified and discussed 10 scholarly articles relevant to the

topic apart from the Bible and the Reading & Study materials. I have selected two resources

which are related to the practice in health care such as allied health profession, nurse, physician

and administration. The sources indicated and provided documents my background on the topic

and is a source of analysis and research for my research paper.

Sources

Bowblis, J. R., & Brunt, C. S. (2013). Medicare Skilled Nursing Facility Reimbursement

And Upcoding. Health Economics, 23(7), 821-840

Goldberg, S., Sander, F., & Rogers, N. (1992). Dispute resolution. Boston: Little, Brown

& Co.

Halpern, M. T., Romaire, M. A., Haber, S. G., Tangka, F. K., Sabatino, S. A., & Howard, D. H.
MEDICAL CLAIM REIMBURSEMENT

(2014). Impact of state‐specific Medicaid reimbursement and eligibility policies on

receipt of cancer screening. Cancer, 120(19), 3016-3024

Kaldjian, L. C. (2013). Communicating moral reasoning in medicine as an expression of respect

for patients and integrity among professionals. Communication & medicine, 10(2), 177.

McAdam‐Marx, C., Unni, S., Ye, X., Nelson, S., & Nickman, N. A. (2012). Effect of Medicare

reimbursement reduction for imaging services on osteoporosis screening rates. Journal of

the American Geriatrics Society, 60(3), 511-516.

Neufeld, J. D., & Doarn, C. R. (2015). Telemedicine spending by Medicare: a snapshot from

2012. Telemedicine and e-Health, 21(8), 686-693.

Peasah, S. K., McKay, N. L., Harman, J. S., Al-Amin, M., & Cook, R. L. (2013). Medicare non-

payment of hospital-acquired infections: infection rates three years post implementation.

Medicare & medicaid research review, 3(3).

Sohn, D. H. (2013, February 15). Negligence, genuine error, and litigation | IJGM. Retrieved

from https://www.dovepress.com/negligence-genuine-error-and-litigation-peer-

reviewed-article-IJGM

Sohn, D. H., & Bal, B. S. (2012). Medical malpractice reform: the role of alternative dispute

resolution. Clinical Orthopaedics and Related Research®, 470(5), 1370-1378

Brief description of the content and how it is relevant

Bowblis, J. R., & Brunt, C. S. (2014). Medicare skilled nursing facility

reimbursement and upcoding. Health economics, 23(7), 821-840. The above article relates to

the reimbursements process done by the Medicare skilled workers having advanced Skilled

Nursing Facilities (SNFs) and are involved in adjusting payments based on the monthly
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minutes therapy provided to assess the patient functionality. To increase revenue, additional

therapy is provided but no relationship can be detected relating to the functionality score of

the up coding. The article elaborates on the consequences of the difference in the regional

variation of payments of SNFs received because of the factors related to geographical

differences. The article is the first of its type to apply the concept of geographical variation in

Medicare generosity reimbursement and it empirical confirms the difference that exists

among various resource utilization groups. It is confirmed that reduction of the financial

incentive up codes the Medicare savings in significant ways.

Centers for Medicare and Medicaid Services. (2015). Accountable care organizations

(ACO). nd http://www. cms. gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.

Html. Principles covered under this article include the comprehensiveness and being patient

centeredness. The administrative complexity related to the wide range of the documentation

that need precertification, billing and credentialing of forms eliminates time through clinical

care mechanism. Inability to state the benefits and value of the alternative treatments,

providers and health plans prevents the consumers from knowing facts hidden behind. The

article basically talks on how to target the payer and the system of payment in improving

outcomes and lowering opportunities. It leads to simplification of administrative work,

payment consistency and redesign of the payment to focus on more incentives such as value

and results.

Goldberg, S. B., Sander, F. E., Rogers, N. H., & Cole, S. R. (2014). Dispute

resolution: Negotiation, mediation and other processes. Wolters Kluwer Law & Business.

The article examine the importance of using an alternative dispute resolution mechanism in

resolving medical problems. The alternative dispute resolution out of courtroom may imply
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using apology, arbitration and litigation. The option is better for both the defendant and the

accuser. Costs will be saved and more time will be dedicated towards remedying the situation

at hand.

Halpern, M. T., Romaire, M. A., Haber, S. G., Tangka, F. K., Sabatino, S. A., &

Howard, D. H. (2014). Impact of state‐specific Medicaid reimbursement and eligibility

policies on receipt of cancer screening. Cancer, 120(19), 3016-3024 The state Medicaid

programs are less prone to cancer screening and consequently more likely to be have tumors

embedded at an advanced stage compared to those without insurance. The article tries to

postulate whether the reimbursement policies and medic aid eligibility affect the cancer

screens on cervical, breast, and colon cancer among the beneficiary of the Medicaid. To

undertake the study, 46 states participated and the cross sectional analyses of regression was

done.

Kaldjian, L. C. (2013). Communicating moral reasoning in medicine as an expression

of respect for patients and integrity among professionals. Communication & medicine, 10(2),

177. The articles confirms that increased costs rarely impact on the quality of services

provided. Key elements of comprehensive treatment need to be incorporated to provide

comprehensive treatment. The improved treatment helps reduce penalizing the physicians

that have opted to treat patients that are sicker. The severity of the patient’s conditions will

impact on the comprehensive care treatment.

McAdam‐Marx, C., Unni, S., Ye, X., Nelson, S., & Nickman, N. A. (2012). Effect of

Medicare reimbursement reduction for imaging services on osteoporosis screening

rates. Journal of the American Geriatrics Society, 60(3), 511-516. The article talks about the

current procedural terminology codes that were used. The article elaborates on how the BMD
MEDICAL CLAIM REIMBURSEMENT

screening rates done could not impact the Medicare eligible women after reduction in

reimbursement. The number of women diagnosed from the fracture process increased and it

still remains unclear what causes the sudden increase. The testing rates did not reduce at a

rate compared to the reduction reimbursement that had been anticipated. Before and after

Medicare reimbursement was done and was expected to save more than $2.8 billion in period

of 2 years.

Neufeld, J. D., & Doarn, C. R. (2015). Telemedicine spending by Medicare: a

snapshot from 2012. Telemedicine and e-Health, 21(8), 686-693. The article examines the

extent and usage of the telemedicine within the health sector. Cost projections have been

done with more cautious legislations being done on the beneficiary of the Medicare. With

increased interest in dealing with Medicare expansion, the telemedicine services have

expanded so widely. The rural beneficiaries have been the principal payers on using the

Medicare services.

Peasah, S. K., McKay, N. L., Harman, J. S., Al-Amin, M., & Cook, R. L. (2013).

Medicare non-payment of hospital-acquired infections: infection rates three years post

implementation. Medicare & medicaid research review, 3(3). The article elaborates the how

some Medicare stopped payment of the infections that have been acquired from the hospitals.

The strategy was adapted in the year 2008 after the Medicare modernization Act was

enforced. The article now examines the relationship between the above named policy and the

vascular catheter assisted infectious to ascertain the relevance of the Act three years after its

implementation.

Sohn, D. H. (2013). Negligence, genuine error, and litigation. International journal of

general medicine, 6, 49.The article explains the importance of care payment that incorporates
MEDICAL CLAIM REIMBURSEMENT

bundles and warranties from several multiple providers. The methods used focuses on

evaluations and surgery received by payers of the projects that range from 40%. The cost of

reducing incidences of hospitalization from people suffering from chronic disease is very

important aspect. Increased reduction in hospitalization can be achieved through self-

management support and patient education.

Sohn, D. H., & Bal, B. S. (2012). Medical malpractice reform: the role of alternative

dispute resolution. Clinical Orthopaedics and Related Research®, 470(5), 1370-1378. The

article describes the purpose of the ADR and its usefulness to the healthcare. The article talks

about the current political and legal developments that favor Alternative dispute resolution,

the obstacles that still remain a challenge. Because of the increasing costs of the healthcare

and associated malpractice, various practices have been adopted such as arbitration,

mediation and apology in the medical field. The purpose of the dispute resolution without

going to courtroom is what matters most in this article.

Analysis

Medicare billing and Medicaid is one of the most important and involved tasks of

medical biller. In general the patient or the medical biller will create a claim of Medicare for

either a third party payer of the private. The claim should have proper information

concerning the procedures that was done, the diagnosis listed, place of service and the NPI.

The prices of the procedures must be listed. The patient should always get reimbursed from

the provider of the services as opposed to the payer. The Medicaid is last resort payer to the

service that is billed. If the patient has an insurance plan, the plan should be billed before the

Medicaid. Many Medicaid billing covers a larger number of medical services apart from the
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Medicare, implying that the program has few exemptions. Since the existing process of

billing medic aid is expensive and difficult, simpler ways should be automated and further

research done to reduce the time and costs of billing.