Healthcare Information That Helps to Reinforce Career Experience
Jennifer A. Dresen
Lakeland College

Healthcare Information That Helps to Reinforce Career Experience
There are a lot of different aspects to look at in the healthcare industry, which can make it feel a little overwhelming at times. The more that I continue to learn, the more comfortable I feel working within this ever changing industry. I currently work for Rehab Management Solutions, which is a practice management company for multiple physical therapy clinics across the United States. In our office we provide services such as; Managed Care, Preliminary Systems, Billing & AR Management, Marketing, and Clinical Growth & Development. A lot of the topics that we have discussed in the course so far I have heard of, but I did not have extensive knowledge of many of them. Below are a few of the topics that I found most interesting and beneficial to my current position and daily activities. Regulation in the healthcare industry
There is very heavy regulation for entry into all areas of the healthcare industry. States have set requirements on the licensure of healthcare facilities as well as providers. These mandatory licensures have been set to try and protect the public’s safety, welfare, and health. The provider licensing procedures were put in place to create the minimum accepted standards to be able to practice. Providers such as nurses, doctors, physical therapists, and dentists; as well as facilities like hospitals, outpatient clinics, and nursing homes require licensure in order to legally treat the public. The information that I learned in week one on regulation has come in very useful at my current employer. At Rehab Management Solutions our Managed Care Director recently took a position elsewhere, and myself and another coworker have been asked to step up to learn to work this integral aspect of our practice management office. The Managed Care Director was the person responsible for making sure that all of our providers and facilities were licensed and contracted with the necessary insurance companies to ensure reimbursement. I did not have much experience or background with this department, as I have always worked in the Coding and Billing Department. So the information that I learned from the PowerPoint slides from week one as well as the information that was in Chapter 1 of our text, has really come in useful. (Gapenski L. 2013). It has given me more background of the licensure process as well as gives me more of a reason for why we are doing these procedures and why it is such an important process. Not only has it helped me, but I have been able to share my knowledge with my coworker so we both are learning together. I plan on continuing to find more tools to educate myself so I can gain as much knowledge and experience to be able to perform these licensing and contracting tasks and become the go to person within the company for any managed care concerns.
Fee-for-service reimbursement
There are three main methods of reimbursement under fee-for-service reimbursement, these methods are: charge based, cost based, and prospective payments. Within a fee-for-service system, healthcare organizations and providers are paid off of the services that they provide to their patients. The basic principle of fee-for-service is the more services provided, the higher the reimbursement received. In the clinics that I bill for the two reimbursement methods that I see the most are fee-for-service and per diems. Per diem plans are those that reimburse a set daily rate regardless of the amount of time spent with the patient, or the amount of services performed. Our providers need to make sure that they are aware of the type or plan that their patients have in order to maximize reimbursement and ensure that they are remaining compliant with their billing. We need to ensure that the providers are not treating a $55 per diem patient for two hours, and also that we are not billing unnecessary services to our fee-for-service patients just to increase their reimbursement. As I move more into a leadership role within my current company, and think about the future of my career in this field I know that understanding reimbursement within the healthcare industry is very important.
Pay for Performance (P4P) Plans
Many insurers have started to implement reimbursement systems that provide incentives for providers that meet preset benchmarks. A majority of these pay for performance systems that have been introduced provide “bonuses” to the providers or facilities that meet their benchmarks; these set benchmarks are usually based on the quality of care, cost reductions, and outcomes. I do have experience with some of the new reporting systems that Medicare has implemented; programs such as the Physician Quality Reporting System (PQRS) and Medicare Limitation Reporting. PQRS uses both incentive payments as well as negative payment adjustments, payment reductions, as a way to try to promote the reporting of quality information by eligible professionals. (CMS 2014). In 2015 PQRS became mandatory to report on at least 50% of your treated Medicare population, or incur a penalty in future years; up until 2015 this system was optional and those that reported compliantly were eligible for bonus payments. Medicare Functional Reporting requires the reporting of non-payable G-Codes and modifiers to gather data on patient’s functional limitations throughout the episode of care. This data is used to better understand the patient’s ailments, the outcome of treatments, and the expenditures for each episode of care. (CMS 2015). The topic of pay-for-performance is one that I feel that I have pretty good understanding of, and some experience in. Learning about it further in Chapter 3 helped to strengthen my knowledge and understanding of the reasons behind why I do these things daily, why payers are implementing these systems, and why it is so important to the future of our healthcare industry. (Gapenski L. 2013)
I have been in the healthcare field for eight and a half years, and the only thing that seems to remain constant is change. I feel that I have a good amount of knowledge from my current position, but the information that we have discussed in this course so far has only strengthened and reinforced my understanding of these topics. The topics that we have touched upon throughout the weeks have helped to connect the dots to things that I have been currently doing on a daily basis, and have made me think more about the reasons behind why we perform certain tasks the way that we do.

References
CMS. (2014). Functional Reporting. Retrieved February 6, 2015, from http://www.cms.gov/Medicare/Billing/TherapyServices/Functional-Reporting.html
CMS. (2015, January 7). Physician Quality Reporting System. Retrieved February 8, 2015, from http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/PQRS/index.html?redirect=/PQRS/
Gapenski, L. (2013). Fundamentals of healthcare finance (Second ed.). Chicago: Health Administration Press.