Draft of Federal and State Payment Systems

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Running Head: DRAFT OF FEDERAL AND STATE PAYMENT SYSTEMS
Southern New Hampshire University
Title: Final Project Milestone Two: Draft of Federal and State Payment Systems
Name: Arnold Opoku
Course: Healthcare Fin & Reimbursement
Professor: Paul A. VanAssche, JD, MBA/HCM
November 4, 2018

2DRAFT OF FEDERAL AND STATE PAYMENT SYSTEMS
Federal and State Regulations: The present changes in economic policy
The Congressional Budget Act of 1974, an economic policy that provides regulations and
procedures to the Congress changes yearly.The change is made in entitlement, discretionary
spending, social welfare programs, and the tax code. It is built on discretionary spending,
andfunds are renewed each year (Larrat, Rita & Vogenbeg, 2012).
The Pay as You Go Rule is a law that demands a mandatory increase in spending on
entitlement and social welfare programs such as the Medicare. The policy is offset by a reduction
in spending and increased taxation (Larrat, Rita & Vogenbeg, 2012).
Concern for healthcare leaders.
Healthcare leaders need to be cognizant of regulations set by the judicial branch and
Congress. The changes in economic policy can change the structure of healthcare
organizations,reimbursement of stakeholders, the role of a practitioner and it turns apatient’s
treatment(Larrat, Rita & Vogenbeg, 2012).
The extent in which healthcare providers support patient care activities in accordance to
the aims of the Affordable Care Act will determine the success in avoiding legal and regulatory
dilemmas, which involve reimbursements and standards of clinical practice. Furthermore, the
Affordable Care Act promotes an increase in the oversight of fraud and abuse. The ACAwill
continue tightening the legal, regulatory constraints on health leaders while it exposes
stakeholders outside the system (Teel, 2018).

3DRAFT OF FEDERAL AND STATE PAYMENT SYSTEMS
Reporting Requirements
The Medicare-Medicaid Plan (MMP) should occasionally submit performance and
monitoring data to various states. Furthermore, it should document any refusals or outreach
attempts. MMP can report a member as unreachable after three outreach attempts. In addition to
that, the three efforts should specifically target completion of the care plan (Centers for Medicare
and Medic-aid Services, 2018).
Appeals and grievances related to benefits which are supplemental should be reported,
grievances are included in the personal care or home health category.MMPs need to haveentire
membershipirrespective of whether the member is enrolled through the opt-in enrollment or a
passive admission. Nevertheless, Medicaid members should not be included, and the MMPs need
to add members registered in the last day of the period of reporting. The 90 day of admission is
equivalent to three calendar months (Centers for Medicare and Medic-aid Services, 2018).
Opportunities and challenges for healthcare leaders.
Regulatory requirements increase the cost of providing services and care. Healthcare
leaders are overwhelmed by the new reporting requirements and changes that regulate Medicaid
and Medicare eligible healthcare providers. Furthermore, healthcare leaders are burdened with
new standards. The provider needs to engage in information sharing and awareness regularly to
update staff and other stakeholders. Healthcare leaders must do compliance training on reporting
requirements, routine audits and address non-conformity issues that arise due to in compliance
with reporting guidelines (Teel, 2018).
Quality and performance reporting system can be effective enough in affecting the level of
reimbursement. The Physician Quality Reporting System (PQRS) is a quality reporting program