Policies that Influence Medicare/Medicaid Reimbursement Specialists

According to Altman and Frist (2015), a Medicare/Medicaid reimbursement specialist is a health professional in the Department of Financing Healthcare who deals with medical billing activities. To be more precise, their chief responsibilities entail assisting customers with health reimbursement coverage options; processing and monitoring insurance companies to guarantee payment compliance; and working with healthcare providers to secure their reimbursements for services rendered. In this regard, Medicare/Medicaid reimbursement specialists operate in the administrative setting and can work in a variety of fields, including private doctor’s offices, emergency centers, and hospitals. They are also not limited in terms of the type of patients that they can work with as they assist clients of all ages and suffering from different diseases. I have been fortunate to interview with Mr. Scott Owens who is a Medicare/Medicaid reimbursement specialist. From the interview, I have realized that to be a Medicare/Medicaid reimbursement specialist a person has to receive certification from the American Medical Billing Association after passing examinations in fields associated with Information Technology, terminology, insurance, anatomy, cash recovery, and account collections. Consequently, Mr. Scott Owens has also pointed out that their roles and responsibilities are governed by a wide range of policies that directly influence how they accomplish their job.

Policies that Directly Influence how Medicare/Medicaid Reimbursement Specialists Accomplish their Job

Mr. Scott has outlined a variety of policies that directly influence how Medicare/Medicaid reimbursement specialists accomplish their job. The first policy pointed out was with regards to the code of conduct that governs Medicare/Medicaid reimbursement specialists. In accordance with the policy, all finance reimbursement specialists are required to comply with all the federal laws and regulations associated with hospital reimbursements. To be more precise, they are required to adhere to the fraud and abuse laws such as the False Claims Act (FCA), the Anti-Kickback Statute (AKS), and the Physician Self-Referral Law (Stark Law) (Altman & Frist, 2015). The FCA policy prevents Medicare reimbursement specialists from knowingly submitting fraudulent claims to the Federal Government whereby they could face a fine of up to three times the amount sustained by the Government. Consequently, the AKS deters Medicare/Medicaid reimbursement specialists from receiving induced rewards or unlawful remunerations. The Stark Law prohibits Medicare/Medicaid reimbursement specialists from claiming Medicare/Medicaid funds to entities in which they have ownership or investment interests (Oliver, Pennington, Revelle, & Rantz, 2014).

Another policy that directly influences how Medicare/Medicaid reimbursement specialists accomplish their jobs relates to privacy and protection of patient’s information. Medicare/Medicaid reimbursement specialists are obliged by the law to protect and enforce confidentiality of patient’s records in accordance with the Health Insurance Portability and Accountability Act. In this regard, Medicare/Medicaid reimbursement specialists cannot use a patient’s health information for personal reasons other than the intended purpose (Centers for Medicare and Medicaid Services, 2015). In addition, the Medicare/Medicaid reimbursement specialist’s job is directly influenced by the pricing policy that directs all services rendered to a patient to be fair in relation to the contract provisions and legal requirements. Furthermore, another policy that governs how the Medicare/Medicaid reimbursement specialists execute their duties if the adherence to the AONE Nurse Executive Competencies. More specifically, they are required to show competence by having adequate knowledge of their health care environment ranging from acting professionally to having the required skill set to operate on tools during coding. As such, they are required to provide accurate coding and billing, certifying that the health organization has earned the payments requested. They are held liable for billing medically unnecessary services or billing services that are already included in a global fee.

Policies that the Interviewee Would Try to Change if They Could

As per the interview, Mr. Scott outlined that he often faced a wide range of challenges in his daily activities and duties. The most apparent challenge pointed out relate to delays in requesting Medicaid/ Medicare reimbursements for services rendered. This is in relation to the failure to capture patients’ information during admission, which begins at the point of patient’s contact with the healthcare administrators. This subsequently delays the process of claiming reimbursements for services offered under the Medicaid/Medicare programs. The delay is also sometimes caused by errors that are generally made during patient registration upon admissions (Jacobs, 2018). It makes roles and responsibilities of Medicare/Medicaid reimbursement specialists difficult as they have to follow up with patients to correct the health information in order to provide accurate coding. Further delays are caused when the front end staff fails to verify the patient’s health insurance status and coverage, which raises complication later on while claiming for compensation for services offered by insurance organizations. More specifically, there tend to be numerous cases of denials and rejections. Mr. Scott outlined that if there was anything he would change, that would be the process of capturing patient information during patients’ admission.

Mr. Scott also pointed out another significant challenge that is commonly faced by Medicare/Medicaid reimbursement specialists is the failure to inform patients about their financial responsibilities. Most insurance health reimbursements are partly paid by insurance companies as the part is paid by insurance programs such as Medicare or Medicaid. Nonetheless, most patients do not understand their insurance plans, which makes it difficult to fulfill their financial responsibilities (Logan, Catalanotto, Guo, Marks, & Dharamsi, 2015). As a Medicare/Medicaid reimbursement specialist, Mr. Scott delineated that it was his responsibility to ensure that the hospital was fully reimbursed for the services rendered to a patient. However, much inconvenience is experienced by the patient as they do not know what is paid from the pocket and how much is covered by the insurance program. Another challenge that was disclosed during the interview is tedious jobs in filing manual insurance claims. According to Mr. Scott, filing for insurance claims is often a tedious activity, which requires Medicare/Medicaid reimbursement specialists to integrate a variety of data collection tools, while collecting patient data from front end staff and the clinical staff to validate patient’s information and services rendered. Despite some organizations automating the process through Electronic Health Records Systems, there are others who still use the manual process.

Policies that Could Improve Outcomes of a Medicare/Medicaid Reimbursement Specialist’s Job

There is a variety of policies that could improve the outcome of a Medicare/Medicaid reimbursement specialists’ job, particularly with reference to enhancing efficiency of the process. First, health care organizations should integrate pre-services provisions into their health care provision services or within their Electronic Health Records systems (Jacobs, 2018). The pre-service would include patient pre-registration and pre-authorization services, which would save a lot of time during patient admission. The pre-registration service would entail registration of all employees prior to their hospital visit, which would not only save time, but also reduce numerous coding errors that are made in the registration process. This would, in turn, hasten the process of claiming reimbursements for services offered under the Medicaid/Medicare programs. There would be no delays in verifying the client’s information as it would be entered at an earlier date. Consequently, the pre-authorization service would improve the process of insurance claims as the Medicare/Medicaid reimbursement specialists would have authority to access the patient’s information and at the same time protect the information from unauthorized users. This would also enhance efficiency of the claims as there would be no time wasted following up with customers after delivery of health care services.

Another policy that would improve the outcome of the Medicare/Medicaid reimbursement specialists’ job includes directing healthcare organizations to implement financial policies that estimate the cost of service rendered based on a patient’s insurance plan. According to Logan et al. (2015), this would play a significant role in eradicating confusion among patients that is caused by uncertainties on how much the insurance covers and how much they should pay out of pocket. Informing patients about their responsibilities could significantly improve the Medicare/Medicaid reimbursement specialists’ job in placing insurance claims and collecting patient’s portion to fully reimburse healthcare organizations. In addition, a policy should be developed mandating all healthcare centers to train their staff about electronic coding. This is ascribed to the points that there are significant amount of errors that are caused during collection of patient data, which ultimately result to insurance claims rejections. Thus, the policy would improve the Medicare/Medicaid reimbursement specialists’ job by improving the process and efficiency of patient data collection. An administrative policy relating to fee schedules and debt collection should also be integrated within the healthcare organization. This will make the Medicare/Medicaid reimbursement specialists’ work easier as they will be able to follow up on hospital reimbursement funds with not only the insurance organization and with the patients as well.

How a DNP-Prepared Nurse Can Influence Policies that Affect a Medicare/Medicaid Reimbursement Specialist’s Job

The DNP-prepared nurse is well suited to adequately influence policies that affect Medicare/Medicaid reimbursement specialists. This is ascribed to the point that unlike other nursing education programs at the Doctoral level, a DNP-prepared nurse is equipped with knowledge on the meaning and importance of health policy and advocacy. As such, they have necessary skills to become both leaders and political advocates who can significantly influence heath care policies. In accordance with the AACN DNP Essentials, a DNP-prepared nurse is best suited to improve the role of a Medicare/Medicaid reimbursement specialist based on a wide range of elements. First, they are equipped with an essential element of scientific underpinnings for practice (Udlis & Mancuso, 2015). As such, they comprehend the importance using science-based concepts such as automation of insurance claims to enhance healthcare delivery. Second, they are equipped with the element of organizational and systems leadership for quality improvement. Thus, they are very efficient in evaluating, translating, and disseminating research into practice. This shows that a DNP-prepared nurse can research different ways to improve the roles of Medicare/Medicaid reimbursement specialists and integrate policies to improve performance. Last but not the least, advocacy essential in Healthcare Policy can prompt DNP-prepared nurses to identify problems in the process of initiating insurance claims and spearhead legislations to change their policies.

Different ways that a DNP-prepared nurse can influence policies governing Medicare/Medicaid reimbursement specialists are through coalition building, policy intervention, and legislation evaluation (Udlis & Mancuso, 2015). The coalition building approach entails seeking a legislative and regulatory approval for policy agenda. The DNP then forms coalitions among different healthcare organizations with the DNP as its leader facilitating adoption of the policy. Consequently, the policy intervention entails the DNP identifying a healthcare policy that based on their knowledge and skills are geared to improving quality of healthcare delivery and decide to support it. The DNP nurse offers an expert testimony to influence other legislators in supporting the policy. With regards to the legislative evaluation approach, the DNP nurse assesses the likelihood of a policy being accepted or rejected and identifies factors that will likely to lead to its rejection. In the same respect, the nurse programs educators to demonstrate the relevance of the policy to other legislators with the aim of swaying their perception.

Overall, a Medicare/Medicaid reimbursement specialist has been determined as a health professional in the department of financing healthcare who deals with medical billing activities. Their chief responsibilities entail assisting customers with health reimbursement coverage options, processing and monitoring insurance companies to guarantee payment compliance, as well as working with healthcare providers to secure their reimbursements on services rendered. A variety of policies has been observed to directly influence how Medicare/Medicaid reimbursement specialists accomplish their job. The first policy pointed out was concerns the code of conduct that governs Medicare/Medicaid reimbursement specialists. The second policy is associated with privacy and protection of patient’s information. Medicare/Medicaid reimbursement specialists are obliged by the law to protect and enforce confidentiality of patients’ records in accordance with the Health Insurance Portability and Accountability Act. The third pricing policy directs all services rendered to a patient to be fair in relation to the contract provisions and legal requirements. From the interview, the policies that the interviewee recommended for change are associated with delays in requesting Medicaid/ Medicare reimbursements for services rendered; failure to inform patients about their financial responsibilities; and tedious jobs relating to filing in of manual insurance claims. Nonetheless, policies that could improve the outcome of Medicare/Medicaid reimbursement specialists’ job include: integrating pre-service provisions like pre-registration and pre-authorization services, directing healthcare organizations to implement financial policies that estimate the cost of services rendered based on a patient’s insurance plan, and mandating all healthcare centers to train their staff on electronic coding. A DNP-prepared nurse has been determined as best suited to influence the policies that affect Medicare/Medicaid reimbursement specialists through coalition building, policy intervention, and legislation evaluation