HI215: Reinbursement Methodologies
Topic #1: DRGs
Most of the people involved with coding and billing are at least familiar with today’s diagnosis-related group (DRG) system for paying inpatient hospital admissions. Medicare made a dramatic change in 1983 in how it handled hospital payments for its members.
Instructions:
Review the PDF from CMS (Centers for Medicare and Medicaid Services) on Acute PPS system from the reading this unit.
- What is a DRG? What is difference between a DRG and a MS-DRG?
- How are DRGs or MS-DRGs developed and calculated? What are the components of each?
- What are the pros and cons associated with the DRG system?
- How can the DRG affect the hospitals business plan for future growth? Think about how this information would serve you in planning as a manager of a billing department.
HI230: Quality Assurance and Statistics in Health Information
Topic #2: Performance Improvement
Why are accreditation and certification important for the health care facility? In your response explain the performance improvement perspectives of accreditation and certification of the organizations. Be sure to justify your position. Also, share what the requirements are for your state (Mississippi).
Expert Solution Preview
Introduction:
In this assignment, we will discuss two topics relevant to the medical field. The first topic is DRGs which are used for reimbursing hospital admissions. The second topic is about accreditation and certification of healthcare facilities and their importance in performance improvement.
Answer to HI215:
A Diagnosis-Related Group (DRG) is a system used to determine the payments for inpatient hospital admissions. The difference between a DRG and a MS-DRG is that MS-DRGs can be further divided into subcategories.
DRGs or MS-DRGs are developed and calculated based on criteria such as the patient’s diagnosis, procedures performed, age, sex, and other factors. The components of each include the relative weight (RW) and the geometric mean length of stay (GMLOS).
The pros of the DRG system include encouraging hospitals to be more efficient, providing a predictable payment amount, and reducing health care costs. The cons include incentivizing hospitals to discharge patients earlier than necessary, altering care decisions to fit DRG criteria, and not taking into account outlier cases.
DRGs can affect a hospital’s business plan for future growth by incentivizing higher volume, shorter stays, and increased efficiency. As a manager of a billing department, understanding DRGs can help in planning for the hospital’s financial stability and efficiency.
Answer to HI230:
Accreditation and certification are important for healthcare facilities as they signify that the facility meets certain standards of quality and safety. In terms of performance improvement, accreditation and certification provide a framework for evaluating and improving processes, procedures, and outcomes.
In Mississippi, healthcare facilities must be licensed by the Mississippi State Department of Health (MSDH) and accredited by a recognized accrediting body such as The Joint Commission. The requirements for accreditation and certification may vary by state but generally involve a review of policies, procedures, and performance metrics.
In conclusion, understanding DRGs and accreditation/certification are important in the medical field. As medical professionals, it is essential to stay informed about these topics to provide the best care for patients and ensure the financial stability and efficiency of healthcare facilities.
