1. Goals of the Physician Quality Reporting System (PQRS)
The physician quality reporting system is an effective tool that helps the physicians in order to evaluate and measure the processes of health care, the structure of the organization and the perceptions of the patients. The goal of this system is to provide the high-quality health care. Some of the most crucial goals of PQRS include timely care to the patients, patient-centered, effective and efficient.
a. Advantages and disadvantages of the PQRS program
Advantages
In case of the reporting through the claims, it requires only 20 unique Medicare patients
In case of reporting through the registry, it requires normal 20 patients
Disadvantages
The measure of the groups in the PQRS program is very limited
Only registry and claims are used in order for the report
2. Goals of the Value-Based Purchasing System (VBPS)
The value-based purchasing system involves the purchasers of the public sector, the individual consumers for decision making and the health plans. The goals of VBPS are to provide the effective health care services and provide rewards to the health care providers that shows high performance. The main goal of VBPS is to enhance the market share through the consumer, payer, and purchaser.
a. Advantages and disadvantages of the VBPS program
Advantages
VBPS program helps the health care in order to reduce the healthcare waste. It provides a deep focus on the best quality outcomes for the patients.
VBPS helps to increase the volume of the patients. It improves the quality of the healthcare and reduces the waste that helps to raise the patient volume.
Disadvantages
VBPS imposes the financial penalty to the hospitals and the physicians who take care of the patients on the serious health problems
VBPS provides the misleading information to the patients about the health care providers that which physicians provide the best quality services for the lowest cost.
3. Role of Health Informatics Information Management (HIIM) staff in participating in both PQRS and VBPS
HIIM provides an effective role in VBPS and PQRS. It helps to provide the critical thinking skills in both the PQRS and VBPS. It helps to provide the effective communication in the healthcare. HIIM uses the professional standards and provides the ethical decision making in the VBPS and PQRS program. It helps to make different plans in order to reduce the difference in the cultures of the health care (Takian, Sheikh, & Barber, 2014).
B. Role of the quality improvement organizations under the Centers for Medicare and Medicaid Services
Quality improvement organizations
It is a group that helps to improve the quality of care which is provided to the individuals with Medicare. The quality improvement organizations performed their work under the Medicare and Medicaid services and provide help to the providers of the health care in the quality improvement.
Role of the quality improvement organizations
Under the centers for Medicare and Medicaid services, the role of the quality improvement organizations is to provide the improved health and care to the individuals by having the lowest cost. It provides the best quality services to the beneficiaries of the health care and its main role is to improve the efficiency and effectiveness of the health care. The quality improvement organizations provide care that the Medicare must pay only for the necessary goods and services. It also provides protection to the beneficiaries and resolves all the complaints of the beneficiaries. It provides all the necessities of the medical and promotes the quality of the care. The quality improvement organizations enhanced the services of the healthcare by providing the education and work with the patients and families in order to direct collaboration with them (Athamneh, 2014).
C. Importance of the government initiatives
1. Medicare and Medicaid Patient and Program Protection Act of 1987
The underlying act illustrates all the penalties that impose on the criminals for all the acts impacting on the Medicare. This act provides security and protection to the hospitals and the replenish of the drug. It also provides protection to the supplies of the medical that are used by the providers of the ambulance when they transport the patients to the hospitals. This act also helps in resolving the fraud and mistreatment problems that arise in the Medicare and Medicaid programs (Chang & Davis, 2013).
2. Medicare Prescription Drug, Improvement and Modernization Act of 2003
This act is also called Medicare modernization act, however, this act provides the benefit of the drugs through the subsidies and the tax breaks. Several new drugs are expensive so that the patients cannot afford those drugs. The underlying act helps to resolve this problem. The Medicare modernization act provides help in the creation of the new health saving account that replaces the previous health saving account. The new health saving account expands the contributions and the participation of the employer (Doshi, Li, & Puig, 2010).
D. Criminal statutes
1. Stark II
a. Importance of Stark II to health care providers
The Stark II law helps to resolve the problems which arise when the doctors refer to the patients to their own lab in order to reduce the medical cost of the patients. This law helps to reduce the medical cost and stops the self-dealing. This law also prevents the doctors from providing the discount to their regular patients.
2. Anti-Kickback Statute
It is a criminal law that creates restrictions on the exchange of the federal health care programs. This law imposes some penalties on the individuals on the prohibited transactions. According to the Anti-kick statute, the fine for only a single violation is up to $25000 along with the five-year imprisonment (Korn, 2007).
a. The importance of the Anti-Kickback Statute to health care providers
The Anti-kickback statute provides help in order to stop the health care individuals for the paying of referrals. If an individual willfully does the act so the person violates the underlying law. The main purpose of the Anti-kickback statute is to provide protection to the patients and the health care programs for the abuse and fraud.
E. Importance of the Sherman Act, the Clayton Act, and the Federal Trade Commission Act to health care providers
The Sherman Act reduces the financial risk faced by the health care providers; however, it also helps in order to active the staff members of the health care. This act helps to provide the clinical integration plans to the health care providers. The agencies implement the Clayton Act; and the Federal Trade Commission Act in order for the protection of the competition in the health care however these acts provide the broad instruction about the mergers. It provides help to the health care when it has faced a threat of competition. The health care providers can take the benefits from these acts when the competition is much harmed. Both of these acts provide guidelines to the health care providers in the competitive situations and it also provides guidance in the mergers of the health care.
F. Importance of anti-kickback statutes of both Stark II and the Medicare and Medicaid Program Protection Act of 1987 to healthcare providers
The anti-kickback statutes are very important and provide the compensation, ownership and the financial relationship with the health care providers. It helps in providing the home health to the patients, the occupational therapy, provides the durable medical equipment to the healthcare, helps in providing the radiation therapy and inpatients and outpatient hospital services to the patients. It provides restrictions on all the referrals to the health services in case if the physician has the financial relationships. It helps to provide the extreme care to the patients of the health care. It creates restrictions on Stark II and Medicare and Medicaid Program Protection Act of 1987 in order to exclude a person by taking participation in the Medicare and the health care programs if the party is held due to the restricted scheme of remuneration (Kronick & Welch, 2014).
G. Activities of each step of the revenue cycle
Source: (Romney, 2016)
1. Work of HIIM staff members during each step of the revenue cycle in which they would be involved
The professionals of HIIM are multi-talented. HIIM provides education and training to the staff members in order to perform the effective functions in the health care organizations. The staff members of HIIM play an essential role in all the steps of the revenue cycle. The HIIM helps its members to check and evaluate the frequency of the duplicate numbers. HIIM helps in the diagnosis and the information on the each step of the revenue cycle. The staff members of the HIIM help to describe the all the components in the revenue cycle. It also helps in providing the translation of some essential diagnosis in terms of the layman (Hope, 2015).
H. Requirements of the HIPAA Transaction and Code set standard
The HIPAA Transaction and Code Set standard include the essential rules for the electronic exchange of the information of health related. Its main requirement is the standard of the electronic data in order to allow the exchange of information from the computer to computer without the interaction of human. It is the basic requirement of the HIPAA Transaction and Code Set standard that the medical data must be standardized and the proprietary codes must be eliminated. The software is designed according to the coding requirements (Mulreany, 2016).
1. Impact of the requirements on coders
HIPAA Transaction and Code Set standard have a significant impact on the coders. This impact includes the submission of the claims, the status reporting, and the certification of the referrals and the coordination of the benefits. It has a positive impact on the coders in sending the clean claims.
References
Aragón, C., Aguilera, J., & Manrique, J. (2014). Laser-induced breakdown spectroscopy for Stark broadening and shift experiments: Measurement of Fe II and Ni II Stark shifts. J. Phys.: Conf. Ser., 548, 012032. http://dx.doi.org/10.1088/1742-6596/548/1/012032
Athamneh, K. (2014). Assessment of infrastructural determinants for quality improvement programs for healthcare organizations in Qatar. Qscience Connect, 2014(1), 26. http://dx.doi.org/10.5339/connect.2014.26
Chang, T. & Davis, M. (2013). Potential Adult Medicaid Beneficiaries Under the Patient Protection and Affordable Care Act Compared With Current Adult Medicaid Beneficiaries. The Annals Of Family Medicine, 11(5), 406-411. http://dx.doi.org/10.1370/afm.1553
Doshi, J., Li, P., & Puig, A. (2010). The impact of the medicare modernization act of 2003 on utilization and spending for medicare part B-covered biologics in rheumatoid arthritis. Arthritis Care Res, 62(3), 354-361. http://dx.doi.org/10.1002/acr.20010
Hope, J. (2015). How would you show appreciation for staff members' hard work?. Recruiting & Retaining Adult Learners, 17(9), 3-3. http://dx.doi.org/10.1002/nsr.30056
Korn, J. (2007). Electronic Health Records: How the New Stark Law and Anti-Kickback Rules May Help Speed Adoption. Journal Of Oncology Practice, 3(2), 76-77. http://dx.doi.org/10.1200/jop.0722501
Kronick, R. & Welch, P. (2014). Measuring Coding Intensity in the Medicare Advantage Program. Medicare & Medicaid Research Review, 4(2). http://dx.doi.org/10.5600/mmrr.004.02.sa06
Mulreany, M. (2016). Starting out - Standards set in our code were with me every day of my first placement. Nursing Standard, 30(36), 25-25. http://dx.doi.org/10.7748/ns.30.36.25.s29
Takian, A., Sheikh, A., & Barber, N. (2014). Organizational learning in the implementation and adoption of national electronic health records: Case studies of two hospitals participating in the National Programme for Information Technology in England. Health Informatics Journal, 20(3), 199-212. http://dx.doi.org/10.1177/1460458213493196
