Comparative Health Information Management - Essay Example

Running Head: Heath Information Management Managed Care When submitting a claim to an MCO for payment hospitals the International Classification of Disease, Clinical Modification system of coding. Currently the version used is ICD-10-CM as is the requirement of CMS for all claims by the healthcare organizations. For a physician claim the Current Procedural Terminology (CPT) which is alternatively referred to as level 1 of HCPCS system of coding is used. The CPT & HCPCS systems are used to code claims describing physician services for purposes of reimbursement. 2. In the case of two-wager-earner families, individuals are double covered with different insurers. MCOs coordinate benefits by establishing procedures and policies which are used to determine the primary and secondary insurers/health plans. The aim is to ensure any cost that is to be catered for by the other insurer is recovered. There are two ways i.e. Pay and Pursue or Pursue and Pay. 3. Under coinsurance, individuals pay a certain percent of the entire health service costs and then the rest is paid by the insurance company. An individual having a 20 percent coinsurance plan for hospital services for instance will cater for just 20% any time hospitalized the insurer caters for the remaining 80%. In a copayment arrangement on the other hand individuals pay a set amount any time they use a certain type of health service. If ones policy has a co-pay of $10 for seeing a primary care physician then anytime they do so they will pay just the amount and the rest is paid by the health insurance company. 4. There are two major forms of consumer directed health plans. First is the Flexible Spending Account (FSA). The account is set by an employee through the employer to cater for costs of healthcare. Withdrawals can only be made towards healthcare; the deposit amount is predetermined by the individual based on the pay period and is pre-tax. It works on the incentive of “use it or lose it” i.e. any amount remaining in the account at year end is retained by the employer. There is also the Health reimbursement Arrangement or HRA. In this type the employer funds avails funds through a special account for employees to be able to pay for healthcare costs that are unreimbursed. The funds are contributed by the employer and tax exempt for employers. Withdrawals can only be made towards healthcare expenses and funds not used at year end can be rolled to the next year. 5. It is very crucial for MCOs to perform utilization management activities as they not only part of the quality improvement efforts but also contribute to the control of costs. The organization is able to review the services required both prospectively and retrospectively hence make decisions that are informed. 6. EHRs are beneficial to both physicians and patients in many ways. Firstly EHRs make sure information is conveniently available whenever needed and health improves the quality of care. Healthcare coordination is also improved while at the same time physicians are able to practice defiantly and save costs significantly. Patients are able to participate increasingly in their care and ultimately improve diagnostics as well as patient outcomes increasingly become positive. Chapter 5 7. Hemodialysis is a type of dialysis whereby blood is circulated extracorporeally through a dialyzer that helps by removing metabolic wastes and thus maintaining homeostasis. CAPD is where patients can do their own dialysis from just anywhere as very the requirement for specialized equipment is minimal. Patients can dialyze 3 to 4 times every day from home or even at work. CCPD on the other hand uses a machine to carry out peritoneal dialysis once every day while the patient is asleep. The patients are required to visit ESRD facilities just for training, monthly evaluation or in events of complications. 8. Dialysis facilities are surveyed regularly by teams from the State Department of Health to determine their compliance with guidelines as set by the state and federal governments. Another team from of surveyors sent by the CMS conducts validation surveys unexpectedly to evaluate whether the regular surveys by state agencies are in line with federal requirements. 9. Every dialysis patient must have his/her medical information recorded and documented. Important items of information include assessments, patient interventions, outcomes and significant events. This is very crucial information to inform the care given to the patient at any future time. 10. The source of payment for most patients who have been on dialysis for more than 30 months is Medicare. 11. Further to monitoring of quality improvement, ESRD networks also collate and analyize patient data in the specific regions. They also publish annual reports providing information on ESRD patient grievances, status changes etc. 12. It is necessary for dialysis facilities to measure, evaluate and monitor quality indicators as well as other performance elements necessary for quality service. The aim is to attain high standards of quality and activities include adequacy of dialysis, nutritional status of patients and anemia management. Other QAPI activities include monitoring of mineral metabolism & renal bone disease, control of infection, patent satisfaction & grievances, vascular access and identification of medical errors and injuries. 13. The main concern for HIM professionals is with protocols regarding documentation, safe storage, access and retrieval as well as the security of records for individual patients. As the professional may also offer useful advice when it comes to the development of systems for provision of appropriate patient information that can be accessed in a timely manner to both caregivers and facility managers. 14. Both ESRD networks and quality improvement organizations are concerned with the quality of service offered to patients. However, whereas ESRD mainly collect and analyze data, quality improvement organizations mainly set standards for quality and ensure that the same are adhered to by health facilities. The two are thus closely related and ultimately work for the best interest of patients. 15. In consulting for ESRD facilities a health information consultant might find a number of resources very useful. Firstly the consultant needs to have access to the statistics of dialysis patients and their conditions in the particular ESRD regions. The consultant must also be well versed with the regulatory environment, healthcare needs for these patients as well as the quality aspects of healthcare with regard to renal dialysis. In order to succeed the consultant must also have access to patient nutrition requirements, their rights grievances as well as regulations surrounding the documentation, retention and management of patient records. 16. The different types of correctional facilities are as below; a) State Departments of Correction b) Prisons c) Jails 17. Estelle v. Gamble is significant to correctional health care as it brought to the fore rights of inmates to healthcare. Having been injured in the course of duty Gamble was not treated adequately and in fact was discriminated against for failing to work. He was met with delayed treatment and sometimes none at all. He decided to sue and when his case fund way to the Supreme Court in the year 1976, the ruling was that all inmates are entitled to not only human treatment but also access to adequate healthcare. Violation of these rights is against the 8th Amendment. It was the court’s reasoning that inmates can only depend on authorities to receive adequate medical treatment and as such the needs may not be met in the case of failure by the authorities. The failure could cause pain & suffering and amount to torture & lingering death which defeat the purpose of punishment. It is the responsibility of correctional facility authorities to ensure all inmates access timely and adequate medical care. 18. Placing the health services program within the state department of corrections under a health services director (HSD) as opposed to placement under individual wardens has several advantages. It indicates the importance of health care in correctional facilities, facilitates centralization of fiscal management as well as the development of standard operating procedures. It also eliminates conflicts that may arise between the prison officers and healthcare professionals. In essence the HSD is an independent office and therefore streamlines healthcare provision in correctional facilities in terms of policy and management of both finances as well as legal aspects of healthcare in the facilities at a statewide level. 19. The process of accreditation is intimated through completion of an application form providing basic facility information. It is encouraged that facilities assess themselves against set standards in preparation for the on-site survey. During the actual onsite survey, a team from the accrediting body comes on the ground, reviews its findings and submits a report. The outcome is and final decision is reached the evidence of compliance is reviewed and approved. Options include the National Commission on Correctional Health Care (NCCHC), American Correctional Association (ACA) and Joint Commission on Accreditation of Health Care Organizations (JCAHO). 20. Health professionals working in corrections can receive a number of certifications to mark their professional leadership, expertise and commitment to service. Depending on the nature of work professionals receive different certifications for playing important role in public health, working well with others and many others. Professionals from different disciplines are recognized i.e. CCHP, CCHP-A, CCHP-MH, CCHP-P for physicians and CCHP-RN for registered nurses. The certifications can be attained through the NCCHC, ACA and JCAHO. 21. Proponents of contracted services argue that significant cost savings and efficiency levels are realized by the states as well as improvement in quality of care offered. Opponents on the other hand argue that cost savings that are realized by firms are actually at the expense of inmates. Those critical of contracting also argue that the organizations are after profits and as such have no incentive to expend resources on adequate or appropriate services and that the responsibility of punishing criminals is for government alone. On the other hand those in support of the private enterprises hold that profit is actually a motive to give inmates appropriate and adequate care as well as averting litigation. Profit is also cited as a motive for deploying proactive policy measures and programs for reducing costs. According to them government has for a long time failed or been reluctant to achieve this due to the many bureaucracies. 22. The type of health services that correctional facilities may need over the next 10 years will be determined by various factors. Firstly the rate of crime is on the increase and this will mean more people in the facilities hence increase demand for healthcare. An important factor is legislation; following the Estelle v. Gamble the questions of treatment of prisoners as full humans has emerged and legislations regarding the rights of inmates will continue to come. The 8th Amendment for instance is invoked when the rights of patients in terms of access to health are violated or perceived to be violated. The civil society and family members of the inmates will also continue to put pressure on correctional facilities in terms adequate care for inmates. There will also be question of cost playing as a major factor as healthcare costs continue to rise. There is also the general growth in realization among people that prisoners are humans and therefore must be treated as so. 23. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) came into existence to set and publicize the standards for exchanging health information electronically as well as address issues of privacy and security. The rule on privacy protects all health information considered as individually identifiable that is held or transmitted by covered entities or their business associates in any form or media. A concern has arisen on the realization that in events of breaches their lacks a private or individual right for action pursuance of the perceived HIPAA breach. Complaints can only be brought forward Department of Health and Human Services. Complaints are on the rise surrounding breach of privacy and causes of action. HIPAA for instance permits correctional facilities to access and use protected information where necessary to provide healthcare for inmates, for the safety of the inmates and maintenance of good order within the facilities. Such exceptions expose individual inmates while the interpretations may differ depending on the settings. 24. As a new information supervisor having reviewed the situation I will prioritize the issues on order of merit. While it is important to secure inmates’ healthcare information I realize that this is not possible when staffs in the department are adequate and motivated. I will therefore begin by improving the relationships between the department’s employees and those of other units then move to train available staff on the work procedures & expectations while at the same time working to acquire enough staff. Another important aspect the problem is record management; I will move to standardize process, assign staff different roles that complement each other and ensure the health care information records are adequately created, maintained and accessed. Finally I will tackle issues surrounding transfer of information, privacy and security. My recommendations will be as follows a) Hire more staff for the department b) Standardize procedures c) Implement checks and balances d) All employees must have defined job descriptions with clear reporting lines e) Information management should comply with standards. References Ann Peden. (2011). Comparative Health Information Management. Cengage Learning. Read More