What does administration need to do to ensure that the hospital is not submitting claims for services for which payment is not available under applicable rule?

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1) What are the factors (e.g., timely and appropriate clinical services) that determine whether patients at risk for pressure ulcers receive proper skin care?
2)What does administration need to do to ensure that the hospital is not submitting claims for services for which payment is not available under applicable rule? Take into account the role of individuals who may want to become a whistleblower, or qui tam relator under the False Claims Act.
3)Legally, how did CMS go about deciding that it would reduce reimbursement for hospital-acquired pressure ulcers and other conditions? Does this policy make sense to you? Why? Does the policy raise any ethical issues?
4)In what ways might an administrator alter systems to avoid the adverse conditions impacting payment, as described in this scenario? In particular, what, if anything, might a hospital administrator do regarding the skilled nursing facility from which this and other patients come?

Nursing in Politics

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As you have discovered through this course, nurses are influential members of the community and the political system. Therefore, for the purposes of this assignment you will identify a problem or concern in your community, organization, etc. that has the capacity to be legislated. You will conduct research and state a proposal. Through the legislative process, your proposal for the problem or concern may influence an idea for change into a law.
First, refer to the "How a Bill Becomes a Law" media.
http://lc.gcumedia.com/zwebassets/courseMaterialPages/nrs440v_how-a-bill-becomes-a-law-v2.1.php
Then, view the "Bill to Law Process" to watch the scenario.
After viewing the scenario, refer to the "Legislative Assignment." You will need to save the document first in order to use it.
Submit the assignment to the instructor. You also reserve the right to submit your completed proposal to the respective government official. However, this is optional. If you select to submit your proposal as a part of the legislative process, refer to "Find Your Representative" or research the contact information on your own.
3 References is required for this essay
A

Describe the specific objectives of this national initiative and how you can implement this into your clinical setting as an APN to reduce patient errors and improve teamwork and communication

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Answer the following questions in a 2-pages document as two separate discussion topics:
• The Centers for Medicare and Medicaid Services and MACRA Legislation require provider transparency in quality and value care. As an Advanced Practice Nurse enrolled in the Medicare reimbursement program, you will be expected to demonstrate competent, patient-centered outcomes. Describe how you plan to utilize and implement evidence-based practice protocols found from the Agency for Healthcare Research and Quality to ensure competent and safe care for your patients.
• Review the Team STEPPS initiative from the Agency for Healthcare Research and Quality (AHRQ). Describe the specific objectives of this national initiative and how you can implement this into your clinical setting as an APN to reduce patient errors and improve teamwork and communication.

Identify and discuss three basic ways to ensure the accuracy of claims processing within managed care.

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Part 1
1. I am interested in your ideas on how managed care organizations can more effectively prevent diseases or more specifically preventing the spread of disease among its contracted population. In other words, what can HMOs do to promote health and reduce illness rather than treating it after the fact. Address cost implications, patient receptivity, provider cooperation and other factors impacting this issue.
2. One of the cornerstones of Accountable Care Organizations is the use of Evidence-Based Medicine. What is this, what are the negatives of EBM, and how can HMOs encourage the positive benefits of EBM.
3. The Health Care Industry has espoused “quality management” for decades. Please identify and briefly discuss three quality management processes, at whatever level you wish (insurance companies, hospitals, medical groups, nursing homes, etc.).
Part 2
1. Years ago it was quite common for HMOs to offer a wide range of behavioral health services, including in-patient hospitalization. More recently, HMOs have limited in-patient programs and encouraged out-patient services. Discuss some of the reasons for this shift.
2. One of the benefits to patients joining an HMO is the relatively strict peer-review and physician credentialing process required for accreditation. Discuss why the credentialing process is important and how it relates to quality management.
3. Discuss how managed care organizations design, market and sell their products to consumers, including individuals and companies.
4. Years ago when I worked for an HMO is Arizona, we contracted with a private company to provide our HMO with hospital discharge and cost data by physician specialty. We used this data to contract with the more cost effective physicians in the State. In effect, we were “provider profiling”. What are some of the potential negatives with using this type of data in the provider contracting process?
Part 3
1. In an attempt to improve quality in managed care, a report called HEDIS was established and expanded upon over the years. What is HEDIS and what is its proported value to health care?
2. One of the most important documents established between a contracted medical group and an HMO is a DOFR (Division of Financial Responsibility). Discuss the DOFR and identify three reasons why this document is important.
3. The American Recovery and Reinvestment Act of 2009 included a provision to establish the HITECH Act (Health Information Technology for Economic and Clinical Health Act). Identify and discuss three provisions of this Act.
4. Identify and discuss three basic ways to ensure the accuracy of claims processing within managed care.
Part 4
1. ACA requires HMOs to achieve a certain “medical loss ratio”. What is a “medical loss ratio” and why is this an important issue?
2. After the passage of Medicare, the federal government has played a major role in setting health policy. Identify and briefly discuss three federal laws regulating health care which have had a material impact on HMOs and the health care industry in general.
3. Over a dozen years ago, California established the Department of Managed Health Care, one of the first in the nation to recognize that HMOs were different from other forms of health care insurance. Please identify and discuss three major functions of this Department.
4. Incurred But Not Reported (IBNR) in claims processing can (and has) led to insolvency on the part of some medical group. Discuss IBNR and identify several ways capitated medical groups try to address this issue.
5. There are two basic methods HMOs (and other insurance companies) use to rate the risk of providing insurance to employers: experience rating and community rating. Briefly discuss each method and explain the merits and problems associated with each method.