Why Center for Medicare & Medicaid Services (CMS) became more involved in the reimbursement component of healthcare and their involvement impact health care organizations
An understanding of why CMS became more involved in the reimbursement component of healthcare requires a clear understanding of reimbursement. Reimbursement is the process whereby CMS compensates healthcare organizations for the expense they undergo in delivering healthcare services to patients under CMS program (Medicaid, 2013). CMS uses a Prospective Payment System (PPS) wherein CMS pays Medicare payment on the basis of a fixed amount that is predetermined (CMS, 2013). There are different PPSs based on nature of the healthcare service provided, such as acute inpatient service, and quality of service offered. The primary goal of increased involvement of HMS in reimbursement is to alter staff behavior in the effort to improve the quality of service offered by various healthcare organizations. Such behaviours changes that are expected to improve service delivery include adherence to guidelines, establishment of positive organizational cultures, drugs prescription especially the prescription of antibiotics (Stone et al., 2010). Consequently, this is aimed at making healthcare organizations to become learning institutions where various professionals seek to enhance their professionalism to improve service delivery.
Tools that can be implemented to ensure an organization is meeting the policies and procedures set forth by CMS
The primary concern for reimbursement is to ensure that healthcare organizations deliver healthcare services effectively and efficiently. Accordingly, CMS established the PPS as a tool to ensure that healthcare organizations work towards this goal (CMS, 2013). Therefore, the organization can use the PPS to ensure that it meets the guidelines established by CMS. There are several PPSs such as PPS for home health agencies, PPS for hospital outpatient services, PPS for inpatient psychiatrist facilities, PPS for long-term hospital services and PPS for skilled nursing facilities among others (CMS, 2013). Accordingly, by understanding these different PPSs, the organization will be in a good position to understand what it needs to do to ensure that it meets established guidelines to receive reimbursements. Average Sales Price (ASP) for drugs will also help the organization to ensure that it prices prescribed drugs in accordance with CMS guidelines (CMS, 2013).Three tools from the CMS Web site that are helpful to achieving the goals set forth by your organization
In line with the primary aim of CMS in becoming more involved in reimbursement component of healthcare, the organization aims at providing high quality healthcare and nursing services by doing the following:
- Subjecting healthcare and nursing service providers to continuous training to enhance their competence; and
- Conducting close monitoring the service provided
With this respect, the following tools established by CMS will help in realizing these goals:
- Skilled Nursing Facility PPS: this tool helps in reimbursing healthcare organizations based on the quality of nursing service provided, which will aid in ensuring that the organization has skilled workforce and up-to-date nursing facilities (CMS, 2013).
- Physician Feedback Program: this program will provide the organization with relevant information to aid them improve the quality of service they deliver (CMS, 2013)
- Fee for Service: this tool will enable the organization to provide appropriate services such as conducting tests to ensure that patients receive high quality healthcare.
References
CMS. (2013). Prospective Payment Systems- General Information. Accessed November 29, 2013 from http://cms.hhs.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/index.html
Medicaid. (2013). Telemedicine. Accessed November 29, 2013 from http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Telemedicine.html
Stone, P. W., Glied, S. A., McNair, P. D., Matthes, N., Cohen, B., Landers, T. F. & Larson, E. L. (2010). CMS Changes in Reimbursement for HAIs. Med Care, 48(5), 433-439.
