Billing and reimbursement

In the United States, the 1996 HIPAA legislation (the Health Insurance Portability and Accountabflity Act) resulted in the designation of six required code sets for billing and reimbursement. These are fisted in Table 18-2. 

Project ImPACT is one of few studies that reports actual billing and reimbursement results. Both patients and insurers were billed for services. On average, pharmacists billed 28 for counseling services and 27 for lipid profiles. Seventy-five percent of patients billed paid an average of 35 per visit, and 53% of third-party payers paid an average of 30. Reimbursement by third-party payers was more frequent, however, for lipid profiles than for counseling. 

Barish M (2004) Billing and reimbursement of virtual colonoscopy. Fifth Annual Symposium on Virtual Colonoscopy, Boston, USA... 

At the simplest level, drug companies seek FDA approval to do anything that involves the testing of therapies in humans. The FDA authors and publishes manuals and other publications that establish the guidelines for Best Clinical Practice which insurers such as HMOs use to guide their own activity of reimbursement of medical bills, and so on. 

In the case of Medicare and Medicaid, once the federal government has approved a therapy it would be very difficult for a Medicare and Medicaid payor - either public or private - to reject claims that have been properly billed and coded. However, that might not be the case for the private payers, simply because the FDA has approved a therapy for reimbursement, as... 

American Society for Apheresis (ASFA), Nashville, TN (2005). Therapeutic Apheresis. A Guide to Billing and Securing Appropriate Reimbursement. ASFA. 

While the funded mandate would cover all insured persons, the voucher provision would cover uninsured children and adults, who would receive immunizations from health care providers oftheir choice, conditional onthe provider s being willing to accept the vouchers as payment in full. The value of the voucher would equal the fixed-dollar subsidy paid to health plans. Participating providers would collect the voucher at the time of service and submit it to the government for payment. The committee considered alternative approaches to the voucher system - from an electronic card system to simply reimbursing providers who submit a bill for each vaccination administered. The committee did not endorse any particular approach, although the hxed-dollar subsidy appears to have been preferred. 

From pharmacy s perspective, MTM is a set of services provided by pharmacists to improve outcomes from medications (Table 17-2). A positive aspect of the MMA is that pharmacists were named as one provider of MTM, and this has provided pharmacists with a long-sought opportunity to bill some insurance plans for their clinical services. At the same time, the plan sponsors, not Medicare, were given full control over what MTM services actually entail, who can provide the services, and how they will be reimbursed. What remains problematic for pharmacists is that the... 

Before the emergence of managed care, it was largely physicians, acting individually on behalf of their patients, who decided how most health care dollars were spent. They billed for their services, and third-party insurers usually reimbursed them without asking any questions, because the ultimate payers—employers—demanded no greater accounting. Now, many... 

Although reimbursement is often cited by pharmacists as the paramount barrier to the widespread dissemination of disease management, other troublesome yet surmountable obstacles exist. - Even when reimbursement is assured, the requirements accompanying billing can be time-consuming and costly. As in other medical fields, the paperwork required to document encounters and apply for pharmacy service reimbursement from various payers in different practice settings is not uniform. The information... 

In 1965, two significant actions occurred that promoted formulary systems. Medicare administrators borrowed freely from ASHP s publications to create standards for institutional health care resulting in a Medicare bill listing the use of a formulary system among the eligibility requirements of Medicare reimbursement. Also, the loint Commission required an active pharmacy and therapeutics (P T) committee for hospital accreditation. 

It is essential that properly trained and knowledgeable personnel staff the billing department to avoid rejection and incorrect payment by the CMS. The reimbursement rate for PET studies is at the high end, and many PET centers are paying special attention to the billing process and employ a skilled billing individual as a special point man to concentrate on PET reimbursement. The point man interacts with the payers to clarify the criteria of these studies and explain to them the appropriateness of each PET study. 

In 2009, members of the U.S. House of Representatives introduced a bill that would allow Medicare to reimburse providers for telehealth services, clarify the credentialing needs of telemedicine practitioners, and create new grant programs to help the medically underserved via telemedicine. This reflects a belief, shared by many, that telemedicine... 

Calls made by the Seattle subscriber in Miami are recorded and, through a clearinghouse function that usually involves a third-party vendor, the Seattle system eventually receives the data so that a bill can be rendered to the customer. The Miami system is ultimately reimbursed for these calls as part of this clearinghouse function. 

Maybe your organization simply can t afford to foot the entire bill for the conference. If the conference is important to you, and some should be, negotiate some sort of partial reimbursement. In fact, you might even be more diligent in what you do at the conference and how you follow-up on it if you have to pay for some or all of it yourself... 

Less reimbursable expenses Expenses (e.g., travel, copying) billed to clients and paid to or due to the consulting firm (excludes markup, overhead, etc.). This revenue comes in, but is immediately used by the firm to reimburse expenses— no gain here for the firm. Therefore, reimbursable expenses are subtracted from the total revenues. 

Less non-reimbursables Expenses incurred as a result of projects, but not bill-able to client (e.g., unexpected lab test needed and not covered in contract or acceptable to client as a contract change). Also includes invoices that were not paid and are written off. Non-reimbursables are subtracted from net revenues. 

The provider is reimbursed for each individual service performed (diagnostics, surgery, tests etc.) for every patient. This is often called retrospective cost-based payment, as providers submit bills to payers for incurred costs, only after completing the relevant services. Note that the payer bears full risk as it must pay for all service, whether or not necessary. The temptation for charging for unnecessary services (not verifiable) has been discussed earlier it increases the costs of healthcare. The patient usually does not object to additional and/or expensive services as he/she is not asked to pay for it directly. The built-in moral hazard and patients acquiescence make this method of payment unsustainable. It has some advantages, however. It can be easily developed and implemented, and it more accurately reflects the work actually done and the efforts expended. 

A more moderate bipartisan product habdity bill was introduced in the Senate. This legislation does not require losing parties in a lawsuit to reimburse adversaries for legal expenses and does not include a cap on noneconomic pain and suffering damages. However, the House s cap on punitive damages is retained, as well as new protection for retailers and wholesalers. This bill was more favorable to the Administration. 

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