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Medicare Reimbursement - Essay Example

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Medicare Reimbursement Author: Date: Scenario 1 Medicare is an insurance provided by government to cover supplies and the services that are needed for the treatment of a medical condition (Medicare, 2013). Mrs. Zwick has Medicare part A, B, and D. Since Mrs…
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Medicare Reimbursement
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Download file to see previous pages Part A will cover the inpatient expenditures of Mrs. Zwick since she was in SNF a whole of 40 days. Part A covers full expenses for SNF for the first 20 days and after that it requires the policy holder to pay $148/ day up to 100 days. Part B will cover the equipment charges for the patient. Under the DME (Durable Medical Equipment), the walker that has been prescribed for Mrs. Zwick, will be paid for by Medicare. Mrs. Zwick will have to pay 20% of the amount that has been approved by Medicare, whether she chooses to rent it or purchase it. Part D will cover the drugs that have been prescribed by the doctor under the Medicare Prescription Drug Plan (PDPs). Mrs. Zwick has authorization that these drugs are medically necessary for her, but she will need to ascertain the quantity of the drugs. Step therapy will be applied to see if similar low cost drugs will be effective in the treatment, only then will Plan D cover the prescription drugs. The actual cost will depend n the type of drug used. Since Mrs. Zwick developed a Catheter Associated Urinary Tract Infection which was an HAI (Hospital Acquired Infection), and which could have been avoided by following infection control steps recommended by the CDC, Centers for Disease Control and Prevention (Medicare, 2013), thus the hospital will have to cover all the inpatient and SNF costs that have occurred after the acquired condition. In 2008, Medicare centres started to adopt a “no pay” policy for infections and complications acquired from the hospitals (O’Rielly, 2012). These hospital acquired conditions can be prevented and should be paid more attention to. CAUTI is one of the 10 conditions that are targeted by the CMS (Centres for Medicare & Medicaid Services) policy. CAUTI is the most preventable hospital acquired infection, a research “Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs”, revealed that 65% - 70% cases of CAUTI are preventable by adopting certain practices (Umscheid, Mitchell, Doshi, Agarwal, Williams & Brennan, 2011). 80% of Infection control professionals are of the opinion that such a policy from CMS has led to a greater focus on healthy practices and prevention of such acquired conditions (O’Rielly, 2012). Under the Deficit Reduction Act (DRA), hospitals will have to report secondary diagnosis, which will not be subjected to payment by Medicare unless they were present on admission of the patient (Paddock, 2007). But the medication and walker prescribed by the doctor will be covered by Medicare. After being admitted to the hospital, Mrs. Zwick developed an HAI, which could have been prevented by following control steps by the hospital. Ethical implications of such hospital acquired infections can be great. Mrs. Zwick suffered from pain tremendously due to the infection and had to stay in the SNF for an extra 19 days. Due to the carelessness of the hospital, the infection was caused, which led to taking of HIV antibiotics for Mrs. Zwick. Taking so many high potency medications at the age of 77 can be extremely harmful for the patient, as it can lead to further complications. The new rule may force the hospital or centre to compensate for the financial aspect but by all means the implications of such infection in terms of pain, time and extra high potency medication have to be borne by the patient him/herself. Scenario 2 COBRA (Consolidated ...Download file to see next pagesRead More
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