A Definition of Medical Terms - Research Paper Example

? Medical Financial Definition of Terms of A Definition of Medical Terms PMPM Billing for Medicaid Patients with chronic diseases (AIDS/HIV) The Per Member per Month is a payment methodology, which is applied by the New York Medicaid Health program to pay health providers. “This billing methodology is used to indicate the expenditure of the health care system in provision of medical services” (Wodchis, Hirth & Fries, 2007). The total sum of the medical care costs for every enrolled member is derived in the calculation of the PMPM amount. The PMPM is used in the analysis of the parameters of the different health status of the patients. The PMPM feed paid to the health home care providers is determined by several factors (Wodchis, Hirth & Fries, 2007). The health home program in the New York Medicaid adjusts the PMPM that is paid to the health care providers according to the enrollment volume, region, and the case mix. There are plans to incorporate the patient’s functional status in the near future by the New York Medicaid program as one of the determinants of the consideration in paying the Health Home providers. The New York Medicaid program provides for payment of a case finding Per Member per Month bill, which is a cheaper amount. “The case finding PMPM is provided during the first few weeks of the program to cater for reimbursement of engagement and outreach services” (Centers for Medicare and Medicaid services, 2011). The provisions of the New York Medicaid are that the billing of active medical care management of the enrolled patients is only made when a health care manager is assigned to the patient. “The New York Medicaid health home program has various managed care plans, which give the guidelines for the payment if the contracted medical professionals” (Centers for Medicare and Medicaid services, 2011). These providers are usually paid at the rates, which are set by the state in the payment for the medical services of the Health home program. Capitalization in Medicaid The term capitalization in Medicaid refers to the inclusion of the medical expenses in the cost of the medical care given to the enrolled patients. Since the federal government meets the cost of medical care in Medicaid, the capitalization is used to ensure that all medical expenses including the payment of the providers and the expenses of purchase of drugs are paid for and accounted for (Centers for Medicare and Medicaid services, 2011). Acuity score in Case Management Medicaid “The term acuity score in case management stands for the levels into which patients are assigned depending on their health status” (Sparer, Brown & Cover, 1999). In Medicaid, a specified criterion is used to categorize patients into levels with point values called equity scores which very according to the life area that the condition of the patient is allocated to. The acuity score of the patient is assigned under two life areas. These are the basic and medical needs. Each one of the life areas has different levels with corresponding points or acuity scores (Sparer, Brown & Cover, 1999). According to Meade and Pope (2007), in Medicaid, the first level of the basic needs life area has one point and it includes various basic needs. These are sustenance items such as clothing and food. The Medicaid provides that the items in this level are made available through the means of the patient. The second level in the basic needs life area has an acuity score of 4 points. The needs in this level are for the sustenance of the patient. According to the provisions of the Medicaid program, the patient should be able to meet these needs with occasional assistance. “This means that emergence assistance is not required in this level. The assistance needed to perform the ADL by the patient who scores 4 points is usually weekly” (Meade & Pope, 2007). The third level of the basic needs life area is where the acuity score of the patient is six points. At this level, the patient requires routine help in the access of basic needs and this should be supported by patient history of difficult of access to the assistance programs by his or her own (Meade & Pope, 2007). The forth level in the basic needs life area involves an acuity score of eight points by the patient. At this level, the patient has no access to basic needs such as food. “Patients who score eight points in the acuity score are usually unable to perform ADL and have no home or most of the life sustenance basic needs” (Meade & Pope, 2007). Level one in the medical needs life area of patients in the Medicaid has an acuity score of one point. At this point, the patient is in stable health with HIV health care program being progressive. In the second level in the medical needs life area, patients have an acuity score of four points. The patient requires referral for medical care at this level of medical needs life area. This is due to a brief acute medical condition during the care for the patient. “In addition, a chronic condition that is not related to HIV may lead to the referral status” (Sparer, Brown & Cover, 1999). This level is also characterized by symptomatic HIV with related conditions, which lead to the impairment of the patient’s health. A six point acuity score in the medical needs life area involves patients with poor health with opportunistic HIV infections and many medical diagnoses. At this point, the patients are bound to their homes from where care is provided status (Sparer, Brown & Cover, 1999). The final level in the medical needs life is where patients have an acuity score of eight points and is a medical emergency. The patient is in the final level of HIV and the home care is complicated and intensive. Regulator Requirements in the NY Medicaid Health Home The regulator requirements for one to participate in the Health Home program are the compliances and rules required to be met by the stakeholder of the medical care to endure compliance to the set standards. Both patients and health care providers to help the regulating body in determining compliance therefore file forms. “The New York Medicaid Health Home program requires the agencies of the medical providers to know whom they are employing” (Centers for Medicare and Medicaid services, 2011). This ensures that the health care professionals have licenses for medical practice and that they have supervisors. The patients for the program must be enrolled. This means that they have to meet the criteria laid down by the program. The regulator requirements are the means of determining whether the patients are eligible for the program. This includes application by the patient, which goes through evaluation by the selecting party so that medical assistance is only given to the eligible patients. “Mothership” Lead Health Home In the health home program, “mother ship” lead care is the management of patients by the health care providers, which minimizes the use of drugs. This program includes proper nutrition and exercise, which aims at improving the health of the patient (Northridge, Glick, Metcalf & Shelley, 2011). The Medicaid health home program seeks the use of qualified medical care providers who would effectively help the patients who are enrolled in the program to improve their health by minimal use of drugs (Centers for Medicare and Medicaid services, 2011). Fee-For-Service In Medicaid and care management health homes, fee for a service is the implementation of the accountability for the medical services given to the enrolled patients in terms of the payment for the health care (Meade & Pope, 2007). The fee for a service is a program, which determines the payment of the medical programs by the state, or insurance companies (Centers for Medicare and Medicaid services, 2011). The aim of the fee for service program is to promote efficient and effectiveness in the payment for the medical care and the management of services by the Medicaid health homes program. Billing process for Medicaid Health Homes The billing process in the Medicaid health program is the protocols used in the payment of the medical care. This includes the process of obtaining funding from the federal government, budgeting for medical supplies, paying the suppliers and health care providers and other emergency medical services such as ambulatory services (Centers for Medicare and Medicaid services, 2011). The billing process must be efficient to ensure that the home health care is provided efficiently to the enrolled patients. References Centers for Medicare and Medicaid services (CMS), (2011). Medicaid. US Department of Health and Human Services. Retrieved December 1, 2011 from https://www.cms.gov/home/medicaid.asp Meade, R., & Pope, A. (2007). Managing billing compliance during clinical research amid changing Medicare coverage. Journal of Health Care Compliance, 9(5), 5-10, 70. Northridge, M., Glick, M., Metcalf, S., & Shelley, D. (2011). Public health support for the health home model. American Journal of Public Health, 101(10), 1818-1820. Sparer, M., Brown, L., & Cover, A. (1999). Implementing Medicaid managed care: The New York city story. Journal of Health Care Finance, 26(1), 1-17. Wodchis, W., Hirth, R., & Fries, B. (2007). Effect of Medicaid payment on rehabilitation care for nursing home residents. Health Care Financing Review, 28(3), 117-29. Read More