Medicare Reimbursement

This assignment will test your knowledge of reimbursement methods of the Medicare program. Below, there are five scenarios that deal with the reimbursement of services provided to a patient enrolled in the Medicare program. Pay close attention to the details in each scenario such as whether the provider accepts Medicare or not. Use Chapter 9 (starting on page 322 of the textbook) to help you with calculating reimbursement. Show your work.

1. Mr. Allgood was just discharged from Meadowview Medical Center after receiving a procedure on his left leg. Mr. Allgood has Medicare coverage, which Meadowview accepts as a participating provider. Meadowview charges $215 for the procedure and the Medicare Physician Fee Schedule (MPFS) for the procedure is $150. What amount would Medicare be responsible for paying?
2. Mrs. Holloway has just received a bill from Oceanside Surgery Center regarding her recent outpatient surgery. Oceanside accepts Medicare assignment and charges $1,000 for her surgery. The MPFS for this surgery is $917. Mrs. Holloway was billed $200 from Oceanside Surgery Center. Considering that Mrs. Holloway is enrolled in the Medicare program, was she billed the correct amount? Explain why or why not.
3. Mr. Tee underwent a medical procedure on his lower back and is a Medicare patient. Mr. Tee has a good rapport with a local medical provider and wants them to do the procedure on him. This local provider is a non-participating provider and does not accept assignment from Medicare. The MPFS for the lower back procedure was $849. What amount is Medicare responsible for paying? How much is the patient responsible for paying?
4. Ms. Poppins has just received treatment for an ailing hip from New Scenery Medical Group which accepts Medicare. New Scenery Medical Group charges $73 for the treatment provided to Ms. Poppins, and the MPFS for the treatment is $70. If Ms. Poppins is responsible for $14, how much can New Scenery Medical Group write-off as uncollectible?
5. Mr. Rogers was seen by Uptownship Healthcare where he was provided medical services to address pain in his abdomen. This provider does not accept Medicare assignment and charges $750 for this type of service. The MPFS for the service is $615. Provide the amounts for the items listed below:
   1. limiting charge,
   2. Medicare’s portion,
   3. the patient’s portion, and
   4. the amount the provider can write off.

To Prepare:

• Review the Resources on healthcare policy and regulatory/legislative topics related to health and nursing informatics.
• Consider the role of the nurse informaticist in relation to a healthcare organization’s compliance with various policies and regulations, such as the Medicare Access and CHIP Reauthorization Act (MACRA).
• Research and select one health or nursing informatics policy (within the past 5 years) or regulation for further study.

The Assignment: (1 page)

Create a 1-page fact sheet that your healthcare organization could hypothetically use to explain the health or nursing informatics policy/regulation you selected. Your fact sheet should address the following:

• Briefly and generally explain the policy or regulation you selected.
• Address the impact of the policy or regulation you selected on system implementation.
• Address the impact of the policy or regulation you selected on clinical care, patient/provider interactions, and workflow.
• Highlight organizational policies and procedures that are/will be in place at your healthcare organization to address the policy or regulation you selected. Be specific.

Consider the case scenario you described in Week 6. Continue with this unfolding case scenario by assuming that the change process is proceeding in an effective manner, and address the following.

1. Provide a concise introduction for your posting.
2. Identify the stakeholders who are impacted by the change at the micro-, meso-, and macro-levels, and discuss how you will engage those stakeholders in the change process.
3. Describe two supportive factors within the system that will facilitate your recommended change.
4. Provide an example of one barrier that may occur that would impede your recommended change.
5. Explain one leadership strategy to address or resolve the barrier, and include your rationale.
6. Recommend one leadership strategy to sustain the change within the context of a complex system, and explain your rationale.
7. Conclude with a succinct synopsis of key points and concise self-reflection of how this topic contributes to your growth as a future leader in the chosen specialty track.

Please note that the requirements for the Peer Engagement Forum are different from what you are accustomed to in the traditional discussion boards in your previous classes. Refer to the assignment guideline and rubric listed below for specific requirements regarding expectations for postings within the peer engagement forum.

Instructors reserve the right to alter assigned peer engagement groups to maximize the student experience and course outcomes. 

Group A:

Healthy People 2010 – is a guide to promote preventative care. Review primary, secondary and tertiary prevention and relate this to women and children at risk in your community. Identify those risk factors that a prevention program could impact the health of the group you identify.This video is the Healthy People 2020 initiative

Group B:

Please research medical technological advances that may be unique to the care of women and children. Discuss how this technology will improve care to women and children. (ideas may be: genetic screening, public health initiatives, mammography, cervical screening, Fetal monitoring, Electronic medical records, telemedicine).Which technological advances have been utilized in your local hospital? How has it impacted the care of women and children?

Please add references and in -text citation