Medicare Skilled Documentation And Reimbursement Process: Fill & Download for Free

If you find one it is because the industry has changed. 30 years ago the 8 years of schooling while paying tuition and working often menial jobs before residency where you were paid a wage that was less than minimum wage and took another 3-7 years at similarly low rate of pay and 80-120 hours per week until one graduated the residency program. So the average physician began earning real earnings (i.e. greater than $25,000 a year) in their early to mid-late thirties.Tuition wasn't huge at state medical schools although private ones had higher tuition levels. Debt load and grinding hours during residency were then repaid with a reasonable lifestyle. Still the average physician made nowhere near $300,000 and still doesn't. When one graduated the doctor was a respected physician or surgeon and most students didn't have huge debt loads. Insurance was known as "hospitalization" because that was all that it covered. The individual paid the physician and for medicines. Neither were particularly expensive. Insurance didn't pay for "everything", but there weren't expensive tests like MRI machines and CT scan was in its infancy. Malpractice cases were rare. People trusted their physicians and surgeons.Over the next twenty years several things happened. First Malpractice cases filed exploded. Although the defendant (physician, hospital etc) won 90% of the time there were serious costs to defending the case. The average defense cost over $100,000 including court costs, expert witnesses, legal fees etc.) even though the case resulted in a judgement for the doctor. Lawyers found newer and more novel ways to sue and started advertising. This resulted in doctors ordering more tests and practicing defensive medicine.Medical care became more expensive. New medicines were developed. MRI scans were developed. Finally the insurance industry developed new contract models. Not each payer group paid the same for the same medical care. Medicare for the elderly and disabled saw their costs exploding and so developed fee schedules that paid much less than what an insurance company pays (currently for a surgeon Medicare is strictly break even....meaning after overhead the surgeon makes zero). Medicaid pays differently state by state....in Louisiana it averages 28% of the orthopedic surgeon's bill (i.e. the doctor takes care of the patient and loses money) in Mississippi it averages 10% (i.e. the doctor takes care of the patient and loses a lot of money). Meanwhile each of these patients has the opportunity to sue you for some perception of substandard care (such as the nurse didn't bring my pain medicines quickly enough).Insurance companies developed the PPO model and the HMO model reducing payments to physicians. At some points in this model primary care doctors were paid a flat fee of $12-$14 per patient per month....zero visits or 15 same payment plus a small co-pay. So the sicker patients were sent on to high priced consultants....it didn't work out well for either the primary care doctor or the patient.Next in 1994 Medicare made a rule change that made the post-operative care included with an operation from 10 days to 90 days. All other carriers followed suit. This resulted in about a 25% reduction in payments related to the operation. More recently if the patient is re-admitted for a complication Medicare refuses to pay anything. So now we test that the patient is not getting a urinary tract infection and keep the patient in the hospital another day. How can we control certain complications? A borderline or early Alzheimer's patient who broke her hip and had surgery is now in rehabilitation. Being out of her usual element she gets confused but hides it. She gets out of bed by herself (yes the rails were up) and slips breaking her wrist. Now she is back at the hospital. We won't get paid to fix her wrist and perhaps some lawyer will say it is our fault that she was not restrained in rehab....she was fine at home and still driving a car.Over the years the "delayed gratification" and respect going to school and working your rear end off for a stable life changed. Tuition rates changed both at undergraduate levels and at medical school. I was charged $2500 a year for University of Maryland school of medicine and there were few fees. Now the exact same state school the total for an in-state student is $33,111 tuition plus $4179 fees plus $2600 for health insurance. Tuition for out of state students is $58,990 + fees plus + medical insurance. None of this includes some additional fees of $680 +100 for Juniors or $175 for seniors. This also does not include books or cost of living. University of Maryland estimates all expenses for in-state students at $62,767 per year and $89,846 for out of state students. This is generally paid with loans some low interest, some high interest.By an online inflation calculator tuition at my medical school should be between $5000 and $7000 depending whether you use the year I started or finished medical school as a comparison in the inflation calculator. There were almost no fees. They provided free medical care to the students but there was a $150 insurance fee and a $56 malpractice fee.So tuition costs went up over 6 fold the rate of inflation. Now the average student exits residency with between $160,000 and $200,000 in debt before they start making money. I was $17,500 in debt in 1986 and no interest accrued during residency. The same inflation calculator says that is equivalent to just under $38,000 today. I know some residents have more than $300,000 debt in residency.Society's attitudes to doctors has changed too. We have gone from honored and respected physicians and surgeons to "providers". Each year the insurance companies pay us less and expect more especially in terms of paperwork to justify payment. They use terms such as "usual reasonable and customary" to define what they should pay. Did they survey physicians to come up with this rate? No they looked at their data and put a 30-50% discount on it and then implied that was what all physicians "reasonably" should charge.Imagine if a plumber you had called gave you an estimate and then after the work was done he handed you a bill for fixing your pipe and you said "most plumbers would only charge half that...here is your payment" and walked away.....he would put a lien on your house unless he had contracted with you for the lower fee. The fact that government through medicare and medicaid utilize about 70% of medical services but pay only 50% of the revenue means the privately insured or uninsured patient is overcharged to compensate. List prices for medical care bear no relationship to the actual cost. For example: A local hospital did my shoulder arthroscopy and rotator cuff repair...a 90 minute operation. The "bill" was over $39,000 but with a $200 co-pay and $4,100 payment from my insurance the bill was "paid in full" and they still made money. Imagine that at 11% of list price the hospital makes a profit. The real person to get burned is the patient not under contract. The marketplace has become so highly distorted with the insured patients paying a huge percentage compared to the care they receive.As an example of this rampant bureaucracy I will use a patient who has never been seen before by the orthopedic surgeon. He comes in with a complaint of knee pain. A medical history is taken, the patient's medications and other medical issues are reviewed, the patient is examined and then on the order of the orthopedist an x-ray of the knee is done. The x-ray is reviewed and the orthopedic surgeon comes to a provisional diagnosis of arthritis based on history, exam and x-rays. He discusses potential treatments offers the patient a "cortisone injection" (there are multiple varieties with different profiles). Upon agreeing to receive the injection the orthopedic surgeon preps the patient's knee and injects the joint....a skill limited almost exclusively to orthopedic surgeons (mostly due to malpractice limitations not that it is that hard). Before injecting the medicine he sees if he can get a sample of joint fluid out for tests (cell counts, dfferential, crystals as in gout or pseudogout). After the injection the surgeon gets free samples of an anti-inflammatory medication out and instructs the patient on use and precautions and writes the patient a prescription, but tells him if the pills don't seem to help don't fill the prescription and call in.The orthopedic surgeon's bill to the insurance company includes initial office visit medium level, x-ray of the knee, cost of the medication used and an injection into a major joint fee. Appropriate modifiers are attached to the injection fee to show it is a separate procedure from the examination (i.e the patient did not just come in for an allergy injection but was examined, diagnosed, and treated). The bill wherein the brand name high quality proprietary medication that was used is also attached as documentation. Pretty straightforward one would think.One would think the following would happen. The patient pays his co-pay. The bill would be reduced to the agreed upon contract rate agreed between the physician and insurance company and the insurance would pay the rest resulting in about 70% payment of the original bill while the rest is written off (no tax savings for write-offs either). The doctor after overhead would make $40-$60 for his services including having an x-ray machine, an x-ray tech, reading the x-ray as well as his expertise in diagnosis and injecting the joint. Remember this is an insured patient. If the patient is on medicare, after overhead he makes zero.What very frequently happens is the insurance company classifies the shot as an "operation", they then apply a rule that you cannot bill for an operation and an office visit in the same day and completely exclude any charge for the office visit (evaluation and management) and pay for the injection at the contract rate and medication per the contract....but may throw out the expensive cortisone mixture that is only available brand name and pay the physician based on the rate for much less effective but generic short acting "cortisone". No where in the contract is this stated or allowed that they pay you only for the cheapest least effective medication in a a group of medications...but they do this quite often. Now: since you "operated" on the patient they now may claim the patient has 10 days of free follow up or some try to take it to 90 though the code books clearly say 0 days follow up for an injection. A joint injection is not an operation.So now using the dictated note/EMR where the examination, history x-rays that were taken and a separate note describing the injection and materials used with another copy of price of medication used is included. This appeal process takes several weeks and is virtually always won by the physician who is telling the truth. Yet this whole process takes employee time (probably $10-$15) for the extra $60 in reimbursement that actually was the pay for that visit. Some physicians have become so tired of the game that they have the patient come back for the injection the next day.The attitude is that all doctors are "rich" and patients shouldn't have to pay anything if they have insurance with an attitude that "I didn't ask to get sick/hurt and I am me....so you should be happy to care for me for free... (meanwhile without the co-pay and deductible the doctor loses money on that patient). Society applauds athletes who make millions and entrepreneurs who invent a new device and make $100 million but not an average physician with a salary of $227,000 doctors for which doctors train 80-100 hours a week for years.My two sons went to MIT as did I. They had two physicians as parents who told them not to go into medicine unless they really wanted to. One is straight CS one is CS/EE. They STARTED at higher than the average pay for physicians. with 4 years of schooling. Once has a BS one a BS and MEng.So now physicians in the US are expected to do more for less, have lost societal respect, and have to go into serious debt and work an insane time period BEFORE they can start earning real money. Older ones are starting to quit. I know a 63 year old primary care doctor who quit because of electronic medical records. I know a vascular surgeon who quit because at age 52 he was tired of coming out at 3 AM to take out appendices (for $400 for his night of sleep every fourth night for the insured or free for the uninsured) or take care of the drunk driver who had ruptured his spleen. He went into hospital management.Most physicians give up a lot of their life to take care of others, yet somehow we respect the person coming up with the next i phone chip more. He will probably never save a life, but the fact that he can validate code for the next chip until it is flawless gets him more pay than someone who may save or improve 1000's of lives.

Understanding all the legal and relational steps needed to care for your parents physically, emotionally and financially are so important and the answers above are great.I want to add, it is extremely important to understand how hospitals, Skilled Nursing Facilities/Long Term Care Facilities (often the same place), home health and other providers spend your parents’ health benefits.For example, hospitals caring for a Medicare patient are paid in a lump sum payment based on a combination of medical diagnosis compared to a peer group with similar diagnosis (Diagnosis related group or DRG). Hospitals “spend down” this lump-sum payment. Hospitals are motivated to diagnose as many conditions as possible to increase the payment and discharge as early as possible to make a profit. Medicare has implemented a program that penalizes hospitals for any readmissions within 30 days, so hospitals are very focused on discharging to providers they trust will take care of the patients to prevent re-hospitalization. Families are often given 2 hour notice of discharge, which can limit families’ choices when its time to find a provider or facility.For patients who are on a Medicare HMO, the benefits in the community can be great; however, if they find themselves in a Skilled Nursing Facility for Rehab, they will not receive the 100 days of Medicare coverage. In my experience, they might be lucky to get 2 weeks. Therapists must submit weekly documentation to the HMO to request further services. The people reviewing the documentation are not health providers and do not understand the clinical components so the decisions are motivated by saving money. I have been on many calls with these case managers fighting for more services. Getting more than 2 weeks is next to impossible, even with excellent documentation by the therapists and nurses.What most families do not know is they can DIS-ENROLL from the HMO and receive full Medicare benefits starting the 1st day of the following month. Instead of 2 weeks, now they have 100 days.Reimbursement is different for each setting and what I know from working in the industry for over 20 years, is that most people do not understand how providers get paid or how much it influences the care decisions.Knowing how providers manage your parents’ benefits and being actively involved in the care planning process improves the quality of care, can save your parents’ money and keep them independent longer.Hopefully this is helpful!If you have any specific questions, feel free to email me at [email protected]

SO EVERYONE IS ON THE SAME PAGE WHEN IT COMES TO A GOAL.A care plan flows from each patient’s unique list of diagnoses and should be organized by the individual’s specific needs.Continuity of care. The care plan is a means of communicating and organizing the actions of a constantly changing nursing staff. As the patient’s needs are attended to, the updated plan is passed on to the nursing staff at shift change and during nursing rounds.Care plans serve as a guide for reimbursement. Medicare and Medicaid originally set the plan in action, and other third-party insurers followed suit. The medical record is used by the insurance companies to determine what they will pay in relation to the hospital care received by the client. If nursing care is not documented precisely in the care plan, there is no proof the care was provided. Insurers will not pay for what is not documented.The purpose of students creating care plans is to assist them in pulling information from many different scientific disciplines as they learn to think critically and use the nursing process to problem solve. As a nursing student writes more plans, the skills for thinking and processing information like a professional nurse become more effectively ingrained in their practice.