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Concepts and terminologies that influence healthcare payment systems Reply to each Peer about their post.

Concepts and terminologies that influence healthcare payment systems Reply 1 to Priscilla:

Health Insurance Portability and Accountability Act (HIPAA) is extremely important because it can impact the compliance and delivery of healthcare for many years. Also, HIPAA can affect a specific part of the healthcare payment systems and its processes.

National Provider Identifiers (NPI) was a part of the HIPAA administrative simplification. It is a 10-digit identification number, which is used for all the healthcare providers. When healthcare providers are assigned an NPI, it will stay in effect for them indefinitely. Adopted under the HIPAA, in the financial and administrative transactions, covered healthcare providers, health plans, and healthcare clearinghouses are required to use the NPI (Centers for Medicare & Medicaid Services, 2019). Also, healthcare providers must be able to share their NPI with other healthcare providers, health plans, clearinghouses, and anyone else who needs it for billing purposes. If a healthcare provider were to submit a claim without an NPI, the claim will be denied, and the healthcare provider will not be able to get paid for their services. Overall, the NPI made the process of the electronic transactions in healthcare much simpler while also helping to improve efficiency of the healthcare system.

Healthcare Common Procedure Coding System (HCPCS) was adopted under the HIPAA, which can help to provide protection of the health information of every patient. HCPCS is a set of codes that are required for healthcare providers in order for them to submit claims to Medicare and other health insurances (AAPC Advancing the Business of Healthcare, 2020). The code set was developed by the Health Care Financing Administration (HCFA), which is now the Centers for Medicare & Medicaid Services (CMS). HCPCS codes are composed of one alphabetical letter and four digits. An example of a HCPCS code is G0379 for direct admission of a patient for hospital observation care (Abbey, 2010, p. 100). When it comes to using the HCPCS codes, the biggest challenge is “to determine which kinds of services, and thus which payment systems, use the given codes” (Abbey, 2010, p. 99). Overall, HCPCS allows for claims to be submitted in a manner that is both consistent and well-organized.

References

AAPC Advancing the Business of Healthcare. (2020). All About HCPCS Codes. https://www.aapc.com/resources/medical-coding/hcpcs.aspx.

Abbey, D. (2010). Healthcare payment systems: An introduction. Boca Raton, FL: Productivity Press.

Centers for Medicare & Medicaid Services. (2019, December 12). National Provider Identifier Standard (NPI). https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand.

Concepts and terminologies that influence healthcare payment systems Reply to Rylee :

Hello Class & Professor Foster,

Happy week 6! This week we were asked to discuss specific factors that influence healthcare payment systems. I have chosen to define and summarize the Health Insurance Portability and Accountability Act (HIPAA) and National Provider Identification (NPI), which I believe we all have had personal experience with within healthcare.

HIPAA was created in 1996 and signed by President Bill Clinton. HIPAA has four main purposes which include; reducing healthcare fraud and abuse, enforcing standards for health information, to assure health insurance portability by eliminating job-lock due to pre-existing medical conditions (DHCS, 2018), and to guarantee security and privacy of health information (which is what HIPAA is most known for among the public). Aside from its main purpose, the acts main components include; prevention of healthcare fraud, rax-related health provisions (DHCS, 2018), focus on healthcare access, group health requirements, and revenue offset for employees (DHCS, 2018).

The National Provider Identifier (NPI) is a unique 10-digit identification number issues to healthcare providers in the United States by the CMS. Healthcare providers who would have an issues NPI number include; physicians, physician assistant, nurse practitioner, nurse anesthetists, dentists, and pharmacists (CMS, 2016). NPI’s can also be used to cross reference healthcare providers who are involved in fraud and medical abuse files.

References:

National Provider Identifier Standard (NPI). (2016). Retrieved December 10, 2020, from https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand

Services, D. (2018). Health Insurance Portability & Accountability Act. Retrieved December 10, 2020, from https://www.dhcs.ca.gov/formsandpubs/laws/hipaa/Pages/1.00WhatisHIPAA.aspx