Federal Government Payer Program - Medicare

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Federal Government Payer Program – Medicare
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Federal Government Payer Program – Medicare
Medicare is a federal government payer program created in 1965 to assist people above
65 years, those with end-stage renal disease, and certain younger people with disabilities get
private health insurance coverage. Its sole purpose was to help improve the health and longevity
of older Americans regardless of their income and medical history. Medicare is categorized into
parts A, B, C, and D to help cover specific services that are offered by insurance companies that
are approved by Medicare. Medicare strives to offer efficient, safe, effective, equitable, timely,
and patient-centered healthcare services. To enable it to achieve these goals, Medicare ensures
that health care institutions and physicians meet licensure, certification, or accreditation
standards before they are approved to provide services to Americans.
Licensing refers to a process of granting permission to health care organizations or
individual practitioners by ensuring they meet minimum standards set to protect public health
and safety. This may either be done through an on-site inspection for organizations or through
some form of examination to prove professional competence. Health care organizations and
individual practitioners are licensed if they met the minimum standards. Accreditation, on the
other hand, is a comprehensive evaluation process done by accrediting organizations to health
care institution’s governance and operations to ensure they meet predetermined criteria and are
consistent with state and national standards. Medicare is keen to work with health care
institutions and individual practitioners that meet licensure and accreditation standards. For
instance, Centers for Medicare and Medicaid Services (CMS) impacts the above standards by
ensuring that suppliers participate in competitive bidding programs for all Medicare Durable
Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS). To be awarded a contract,
the supplier must have the required state licenses and meet all DMEPOS state licensure
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requirements (Ji, 2019). Additionally, the supplier must be accredited by a CMS-approved
accrediting organization for the items in a product category. Therefore, any organization with an
intent to conduct business with CMS, including healthcare institutions, must be licensed by the
state and accredited by a CMS accrediting organization to ensure patient services are efficient,
timely, safe, and patient-centered.
The Centers for Medicare & Medicaid Services (CMS) is committed to improving
quality, affordability, and accessibility of healthcare for all Americans. In CMS, quality
healthcare is given the highest priority and is defined as having properties such as equity,
effectiveness, efficiency, timeliness, safety, and patient-centered. As a result, quality reporting is
an important element and a CMS requirement for all healthcare institutions as it helps guide
quality and performance improvement efforts. For instance, CMS requires health home agencies
to collect and report performance data using a data collection tool known as the Outcome and
Assessment Information Set (OASIS). Recently, CMS updated the OASIS data set to AOSIS-D
to ease home agencies reporting. Quality reporting may also be done on the Medicare.gov
website, where a star rating was introduced to motivate home health agencies to report
performance data.
Haglin et al. defines Medicare reimbursement as the payment that healthcare providers,
suppliers, and physicians receive as compensation for healthcare services rendered to Medicare
beneficiaries (Haglin et al., 2020). Reimbursement for healthcare services at Medicare is done
based on Medicare plans, that is Part A, B, C and part D. for part A and B, Medicare providers
and suppliers send claims directly to Medicare without individuals receiving a bill. However,
depending on whether healthcare providers are participating or non-participating providers, an
individual may be required to pay coinsurance and deductibles. In some instances, an individual
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may be required to pay upfront for services and later file a Medicare claim for reimbursement. In
this case, the claim should be filed within a year from the date of service. Instructions should be
followed strictly while filling the Patient Request for Medical Payment Form. If the claim is
accepted, the reimbursement process begins.
Medicare has made it possible for beneficiaries to enjoy broad access to physicians and
hospitals. Many beneficiaries can obtain care when needed, easily find new physicians, schedule
timely appointments, and, most importantly, have a source of care. However, a small number of
low-income Medicare beneficiaries report some challenges with accessing healthcare or delayed
care due to a lack of finances that limit them from seeing a doctor or taking the recommended
medical tests. Many beneficiaries report that improvements made by Medicare have improved
access to care for older adults and people with disabilities as opposed to those not covered by
Medicare.
Health Information Management (HIM) is the process of collecting, analyzing, and
protecting health information with the aim of providing quality health care (Zeng et al., 2009).
The most important role of a HIM professional is to ensure quality, integrity, and protection of
patient’s health information. This aligns with Medicare’s goal of providing quality healthcare for
all. A HIM professional will ensure that patient information under Medicare coverage is well
protected and available when needed. The availability of the patient data in quality reporting
gives a better picture of whether the patient is receiving better care or not and provide areas that
need improvement under Medicare.

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References
Haglin, J. M., Eltorai, A. E., Richter, K. R., Jogerst, K., & Daniels, A. H. (2020). Medicare
reimbursement for general surgery procedures: 2000 to 2018. Annals of Surgery, 271(1),
17-22.
Ji, Y. (2019). The Impact of Competitive Bidding in Health Care: The Case of Medicare Durable
Medical Equipment.
Zeng, X., Reynolds, R., & Sharp, M. (2009). Redefining the roles of health information
management professionals in health information technology. Perspectives in Health
Information Management/AHIMA, American Health Information Management
Association, 6(Summer).

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Federal Government Payer Program – Medicare

Federal Government Payer Program – Medicare

standards before they are approved to provide services to Americans.

Licensing refers to a process of granting permission to health care organizations or

other hand, is a comprehensive evaluation process done by accrediting organizations to health

Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS). To be awarded a contract,

requirements (Ji, 2019). Additionally, the supplier must be accredited by a CMS-approved

timely, safe, and patient-centered.

effectiveness, efficiency, timeliness, safety, and patient-centered. As a result, quality reporting is

depending on whether healthcare providers are participating or non-participating providers, an

accepted, the reimbursement process begins.

Health Information Management (HIM) is the process of collecting, analyzing, and

need improvement under Medicare.

reimbursement for general surgery procedures: 2000 to 2018. Annals of Surgery, 271(1),

management professionals in health information technology. Perspectives in Health

Information Management/AHIMA, American Health Information Management

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