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Reimbursement, Medicare, And Medicaid

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    Fall 2013

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    Gross domestic product (GDP) is the broadest

    measure of the health of the US economy.

    Real GDP: output of goods and services

    produced by labor and property located inthe United States

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    Unnecessary care

    Consumer attitudes

    Healthcare financing

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    Pharmaceutical usage

    Changing population demographics

    Disease patterns

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    Health disparities based on gender, race, and

    socioeconomic status continue.

    US infant mortality is among the highest in

    the world.US life expectancy is lower than in many

    other developed countries.

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    Four sources

    Government (45%)

    Private insurance companies (35.9%)

    Individuals (15%) Other (4%)

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    Enacted 1965

    Federal funding and control

    Not means-tested (income not considered)

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    Fees paid strictly controlled in 1965 plan

    But new technology not foreseen

    People are living longer

    Burgeoning costs led to a series of costcontrol efforts

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    Enacted 1982

    Prospective payment system

    Payment per case

    Diagnosis-related groups

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    Potential for legal gaming of the system

    DRG creep to higher-level diagnoses

    Some suggest DRGs should have been based

    on severity, not diagnosis

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    State level program

    Medically indigent, blind, or disabled

    Children with disabilities 50% to 83% paid by federal government

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    Enacted 1965

    Federal and state funding

    Administered by the states

    Covers the poorMeans tested

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    Largest groups covered are women and

    children

    But largest expenditures are for aged and

    disabled

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    Also the target of cost control efforts

    Waivers and demonstration projects provided

    for state experimentation

    Goal was to cover more of a statespopulation

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    Managed care is a health plan that brings together

    the delivery and financing function into one

    entity. The goal is to decrease unnecessary

    services, thereby decreasing costs.

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    Military health plan

    Serves:

    Active duty personnel and family

    Survivors of military personnel

    Retired military personnel

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    Provides healthcare services

    to former military personnel

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    Private Insurance

    Individual insurance plan, the insured pays the total

    amount of the monthly premium

    Group insurance plan

    the insured individual and their employer share the

    amount of the monthly premium

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    Health Maintenance Organizations care is directed toward prevention of disease

    patient must see only HMO approved providers

    pay a monthly fee, no additional charge for care

    care from non-HMO provider generally not covered

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    Preferred Provider Organization (PPO) Group of doctors and/or hospitals that provide care to a

    specific group

    PPO provides services to the insured at a reduced rate Usually require a deductible and a co-pay

    Less coverage for treatment provided by non-PPOprovider

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    Indemnity PlanTraditional plan with freedom to visit

    physician of choice

    No referral required by insurance company

    Pay up front

    Get reimbursed amount allowed by insurance

    policy; amounts may vary

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    We must think of our practice within a

    context of organizational viability and quality

    of care.

    We must be able to do financial thinking.We must think of our services in terms of

    value added for patients.

    We must exercise cost-conscious nursing

    practices, including capturing all costs.

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    We must focus on patient needs, not provider

    needs or organizational practices.

    We must provide evidence-based practices

    for the public we serve.We must incorporate and evaluate new

    technologies.

    We must use research to better our

    practices.

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    Accreditation and reimbursement agencies

    require accurate and thorough documentation of

    the nursing care rendered and the clientsresponse to interventions.

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    Strand, J., & Castillo, P. Reimbursement 101.

    Retrieved August 23, 2013, from

    http://www.paeaonline.org/Project04/PM/html/reimbursement/remPPT.htm.

    Yoder-Wise, P. S. (2010). Leadership and

    Managing in Nursing, 5thEdition, Mosby

    Elsevier.

    http://www.paeaonline.org/Project04/PM/html/reimbursement/remPPT.htmhttp://www.paeaonline.org/Project04/PM/html/reimbursement/remPPT.htmhttp://www.paeaonline.org/Project04/PM/html/reimbursement/remPPT.htmhttp://www.paeaonline.org/Project04/PM/html/reimbursement/remPPT.htm

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